THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


DISEASES 


URINARY    ORGANS. 


PRACTICAL  TREATISE 


DISEASES,  INJURIES,  AND  MALFORMATIONS 


URINARY  BLADDER, 


PROSTATE  GLAND,  AND  THE  URETHRA. 


BY 

SAMUEL  D.^OSS,  M.D.,  LL.D.,  D.C.L.  Oxon., 

PROFESSOR    OF    SURGERY    IN    THE    JEFFERSON    MEDICAL    COLLEGE    OF    PHILADELPHIA. 

THIRD  ED1TI0:N^, 

REVISED    AND    EDITED 
BY 

SAMUEL  W.  GROSS,  A.M.,  M.D., 

SURGEON  TO  THE  PHILADELPHIA  HOSPITAL. 

LLUSTRATED    BY    ONE    HUNDRED    AND    SEVENTY    ENGRAVINGS. 


PHILADELPHIA: 

HEI^KY     C.     LEA 

1876. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1876,  by 

HENRY    C.    LEA, 

in  the  Office  of  the  Librarinn  of  Congres?,  at  Washington       All  rights  reserved. 


PHILADELPHIA: 
COLLINS,    PRINTER, 

70j  Jayne  Street. 


BiomedicaJ 
iJlttUy 

100 


PREFACE. 


A  NEW  edition  of  this  work  having  been  called  for,  after 
having  been  out  of  print  for  several  years,  I  have  entrusted 
its  revision  to  my  son,  Dr.  S.  W.  Gross,  who  has  rewritten  the 
greater  portion  of  it,  and  brought  it  fully  up  to  the  existing 
state  of  our  knowledge.  As  he  has  delivered  several  courses  of 
lectures  upon  the  affections  of  the  urinary  organs  in  the  Jeffer- 
son Medical  College,  and  has  devoted  much  study  and  attention 
to  their  practical  details,  I  felt  satisfied  that  the  task  would  be 
thoroughly  executed.  The  chapters  on  Tumors  of  the  Bladder 
and  of  the  Prostate  Gland,  which  add  largely  to  the  value  of 
the  work,  are  entirely  due  to  his  pen.  It  is  proper  to  observe 
that  the  anatomy  of  the  urinary  organs,  and  the  appendix  in 
relation  to  the  prevalence  of  stone  in  the  bladder  and  calculous 
disorders  in  the  United  States,  inserted  into  the  former  editions, 
have  been  omitted  in  this.  To  Dr.  C.  H.  Mastin,  of  Mobile, 
Alabama,  I  am  indebted  for  the  statistics  of  lithotomy  as 
performed  by  American  surgeons;  and  I  am  also  under  obliga- 
tions to  Dr.  Barnes,  Surgeon-General  U.  S.  Army,  for  several 
engravings  illustrative  of  various  topics  discussed  in  these  pages. 

S.  D.  GEOSS. 
Jefferson  Medical  College, 

Philadelphia,  September,  1876. 


OC70>/C*0 


D 


CONTENTS. 


PART  I. 

DISEASES  AND  INJURIES  OF  THE  BLADDER. 


CHAPTER  I. 


INFLAMMATION  OF  THE  BLADDER  AND  ITS  RESULTS. 


Sect.  I.    Acute  Inflammation       .... 
II.    Croupous  Inflammation  of  the  Bladder 

III.  Suppuration  and  Abscess  of  the  Bladder 

IV.  Gangrene  of  the  Bladder     . 
V.    Ulceration  of  the  Bladder    . 


PAGE 

18 
27 
29 
32 
35 


CHAPTER  II. 

CHRONIC  INFLAMMATION  OF  THE  BLADDER  AND  ITS  RESULTS, 

Sect.  I.    Catarrh  of  the  Bladder 

II.    Hypertrophy  of  the  Bladder 

III.    Sacculation  of  the  Bladder 


43 
55 
62 


CHAPTER    III. 

FUNCTIONAL  DISEASES  OF  THE  BLADDER. 

Sect.  I.    Irritability  of  the  Bladder 68 

II.   Spasm  of  the  Bladder 78 

III.  Neuralgia  of  the  Bladder       . 80 

IV.  Paralysis  and  Atony  of  the  Bladder 85 


CHAPTER   lY. 

INCONTINENCE  OF  URINE 


.       98 


CHAPTER   Y. 

RETENTION  OF  URINE. 

Sect.  I.   Symptoms,  Causes,  and  Treatment 105 

II.    Catheterism 121 

III.   Puncture  and  Aspiration  of  the  Bladder 129 


viii  CONTENTS. 

CHAPTER   TI. 

TUMORS  AND  TUBERCLE  OF    THE  BLADDER. 

PAGE 

Sect.  I.    Tumors  of  the  Bladder 135 

II.    Tubercle  of  the  Bladder 154 

CHAPTER  VII. 

VARIX  AND  HEMORRHAGE  OF  THE  BLADDER. 

Sect.  I.   Varix  of  the  Bladder 156 

II.    Hemorrhage  of  the  Bladder 158 

CHAPTER   YIII. 

STONE  IN  THE  BLADDER. 

Sect.  I.    Nature  and  Causes         .        .                 165 

II.    Physical  and  Chemical  Properties 171 

III.  Situation 189 

IV.  Symptoms 191 

V.    Physical  Signs,  Sounding,  Diagnosis 197 

VI.    Pathological  Effects 212 

VII.    Prognosis  of  Vesical  Calculus 215 

CHAPTER    IX. 

TREATMENT  OF  STONE  IN  THE  BLADDER. 

Sect.  I.    Medical  Treatment 217 

II.    Lilholysis 221 

III.  Extraction  of  Calculi  through  the  Urethra 222 

IV.  Lithotrity 224 

V.    Lithotomy .         .         .  238 

Art.  I.  Lateral  Lithotomy 239 

II.  Bilateral  Lithotomy 285 

III.  ]\Iedian  Lithotomy 288 

IV.  Ilecto-Vesical  Lithotomy 291 

V.  Suprapubic  Lithotomy 293 

VI.  Extrapelvic  Lithotomy 296 

CHAPTER  X. 

STONE  IN  THE  BLADDER  OF  THE  FEMALE    .            .           .  299 

CHAPTER    XI. 

FOREIGN  BODIES  IN  THE  BLADDER            .           .          .  305 


GOXTENTS.  IX 

CHAPTER   XII. 

PAGE 
WOUNDS  OF  THE  BLADDER  ,  .  .  .    309 

CHAPTER  XIII. 

RUPTURE  OF  THE  BLADDER         .  .  .  .317 

CHAPTER   XIT. 

FISTULE  OF  THE  BLADDER. 

Sect.  I.    Vesico-Vagiual  Fistule 330 

II.    Vesico-Rectal  Fistule 339 

CHAPTER  XT. 

MALPOSITIONS  OF  THE  BLADDER, 

Sect.  I.    Hernia  of  the  Bladder 343 

II.    Inversion  of  the  Bladder 349 

CHAPTER  XVI. 

MALFORMATIONS  AND  IMPERFECTIONS  OF  THE  BLADDER. 

Sect.  I.    Absence  of  the  Bladder 355 

II.    Bilobed  Bladder 357 

III.  Exstropliy  of  the  Bladder 358 

IV.  Patent  Urachus 368 


PART    II. 

DISEASES  AND  INJURIES  OF  THE  PROSTATE  GLAND. 
CHAPTER   I. 

INFLAMMATION  OF  THE  PROSTATE  AND  ITS  RESULTS. 

Sect.  I.    Acute  Prostatitis 371 

II.    Abscess  of  the  Prostate 376 

III.    Ulceration  of  the  Prostate 381 

CHAPTER   II. 

PROSTATORRHOEA 384 


X  CONTENTS. 

CHAPTER   III. 

PAGE 

HYPERTROPHY  OF  THE  PROSTATE  .  .  .    392 

CHAPTER   lY. 

ATROPHY  OF  THE  PROSTATE  .         .  .  .412 

CHAPTER   V. 

TUMORS  AND  TUBERCLE  OF  THE  PROSTATE. 

Sect.  I.    Tumors  of  the  Prostate  .........    413 

II.   Tubercle  of  the  Prostate 434 

CHAPTER   VI. 

CONCRETIONS  AND  CALCULI  OF  THE  PROSTATE    .    .  426 

CHAPTER   VII. 

HEMORRHAGE  OP  THE  PROSTATE  GLAND     .  .         .      434 

CHAPTER  VIII. 

WOUNDS  OF  THE  PROSTATE  ....    486 

CHAPTER   IX. 

MALFORMATIONS  OF  THE  PROSTATE         .  .  .     439 


PART    III. 
DISEASES  AND  INJURIES  OF  THE  URETHRA. 

CHAPTER    I. 

FUNCTIONAL  DISORDERS  OF  THE  URETHRA. 

Sect.  I.    ^[orbid  Sensibility  of  the  Urethra 441 

11.    Neuralgia  of  the  Urethra 446 

III.    Spasm  of  the  Urethra 449 

CHAPER   II. 

STRICTURE  OF  THE  URETHRA       ....    451 


CONTENTS.  Xi 

CHAPTER    III. 

PAGE 

INJURIOUS  EFFECTS  OF  OPERATIONS  ON  THE  URETHRA  .     489 

CHAPTER   IV. 

HEMORRHAGE  OF  THE  URETHRA  .  .  .     495 

CHAPTER   Y. 

FALSE  PASSAGES  OF  THE  URETHRA  .  .  .     499 

CHAPTER  YI. 

INFILTRATION  OF  URINE  ....     50f) 

CHAPTER  YII. 

URINARY  ABSCESS 511 

CHAPTER  YIII. 

FISTULE  OF  THE  URETHRA  ....     516 

CHAPTER   IX. 

PROLAPSE  OF  THE  MUCOUS  MEMBRANE  OF  THE  URETHRA      .     526 

CHAPTER   X. 

TUMORS  OF  THE  URETHRA  ....     528 

CHAPTER   XI. 

FOREIGN  BODIES  IN  THE  URETHRA  ....     536 

CHAPTER   XII. 

LACERATION  OF  THE  URETHRA  ....  546 

CHAPTER   XIII. 

MALFORMATIONS  AND  IMPERFECTIONS  OF  THE  URETHRA       .     554 

CHAPTER  XIY. 

LESIONS  OF  THE  GALLINAGINOUS  CREST      .  .  .     561 


LIST  OF  ILLUSTRATIONS. 


FIG 
1. 

2. 


9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 

^7, 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
35, 
37. 
38, 
40, 
42. 


Urinary  deposits  in  cystorrbcea 

Keyes's  apparatus  for  washing  out  the  bladder 

General  hypertrophy  of  the  bladder 

Columniform  bladder     .... 

Interureteral  bar  .... 

Mercier's  instrument  for  incising  the  bar  at  the  neck  of  the  bladder 

Mercier's  instrument  for  excising  a  portion  of  the  bar  at  the  neck  of 

tlie  bladder 
Sacculated  bladder         .... 
Sacculated  bladder         .... 
Catheter  syringe  .... 

Female  urinal      ..... 
Male  urinal  ..... 

Gouley's  tunnelled  catheter 
Tapi^ing  tlie  urethra  in  the  perineum    . 
Over-curved  flexible  catheter    . 
Mercier's  catheter  .... 

18.  French  gum-elastic  catheters 
Gross's  prostatic  catheter 
Blood  catheter    ..... 
Silver  catlieter    ..... 
Mode  of  securing  the  gum  catheter  in  the  bladder 
Holt's  catheter    ..... 
Mode  of  holding  tlie  female  catheter    . 
Rectal  puncture  of  the  bladder 

Tube  to  be  worn  after  suprapubic  puncture  of  the  bladder 
Aspirator  .... 

Benign  vesical  papilla   . 
Papillary  fibroma  of  the  bladder 
Multiple  papillary  fibroma  of  the  bladder 
Carcinomatous  vesical  papilla 
Simon's  urethral  specuhun 
Calculus  with  nucleus  of  cork 
Thorny  calculus 
36.  Different  forms  of  calculi 
Pudding-stone  calculus . 
39.  Uric  acid  calculi 
41.  Oxalate  of  lime  calculi 
Hemp-seed  calculus 


XIV 


LIST    OF    ILLUSTRATIONS. 


FIO. 

43, 
4.'). 
46. 
47, 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59, 
62. 
63. 
64. 
65. 
66. 
67. 
68. 
69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 


89. 
90. 
91. 
92- 
97. 
98 
99. 


44.  Cystic  oxide  calculi 
Phosphatic  calculus 
Ammoniaco-niagnesian  calculus 
48.  Fusible  calculi 
Sacculated  calculi 
Encysted  calculi 
Sound      .... 
Hollow  sound 

Sounding  for  encysted  stone 
Sounding  for  stone  behind  the  prostate 
Sounding  for  stone  above  the  pubes 
Cooper's  forceps 

Weiss's  and  Thompson's  lithotrite 
Fergusson's  rack  and  pinion  lithotrite 
60,  61.  Different  forms  of  litliotrite  blades 
English  method  of  seizing  the  stone     , 
French  method  of  seizing  the  stone 
Position  of  stone  for  crushing  . 
Clover's  evacuating  apparatus  . 
Fillet       ..... 
Grooved  staff      .... 
Lithotomy  knife 

Beaked  knife       .... 
The  finger  and  knife  in  the  groove  of  the  staff 
Lithotomy  forceps 

Mode  of  seizing  and  extracting  the  stone 
Lithotomj'  scoop 
Prostate  at  birth 
Prostate  at  4  years 
Prostate  at  12  years 
Crushing  forceps  ... 

Physick's  forceps 

Canula  for  plugging  the  wound  in  lithotomy 
Arterial  compressor 
Double  lithotome  cache 
Bilateral  lithotomy 
Fergusson's  incision 
Little's  director  .... 
Buchanan's  rectangular  staff    . 
Urethral  dilator  .... 
Female  staff        .... 
Forceps  for  extracting  foreign  bodies  from  the  bladder 
Shot  perforation  of  the  bladder  and  rectum 
Sims's  speculum 
Emmett's  speculum 

96.  Instruments  for  vesico-vaginal  fistule 
Bryant's  instrument  for  paring  the  edges  of  the  fistule 
iS'eedle  holder     . 
Hook  for  making  counter-pressure 


LIST    OF    ILLUSTRATIONS. 


XV 


FIG.  PAGE 

100.  Introduction  of  sutures  .            ......  335 

101.  Suture  carrier     ........  335 

102.  Suture  adjuster  ........  335 

103.  Adjustment  of  sutures   .......  336 

104.  Bozemau's  button  suture           ......  386 

105.  Sims' s  catheter  ........  337 

106.  The  cervix  slit  up  to  expose  tlie  fistule  above,  with  the  sutures  in 

position             ........  337 

107.  Case  of  vesico-vaginal  fistule  requiring  obliteration  of  the  vagina     .  338 

108.  Sims' s  operation  of  elytrorraphy  ;  sutures  in  place    .             .             .  347 

109.  Exstrophy  of  the  bladder           ......  359 

110.  Wood's  operation  for  exstrophy  of  the  bladder           .             .             .  365 

111.  Maury's  operation  for  exstrophy  of  the  bladder          .            .            .  366 

112.  Urinal     .........  367 

113.  Abscess  of  the  prostate  .            ......  376 

114.  115.  General  hypertrophy  of  the  prostate        .  .  .  393,  394 
116,  117.  Hypertrophy  of  the  middle  lobe  .            .            .            .  .394 

118.  Hypertrophy  of  all  the  lobes     ......  395 

119.  Angular  curvature  of  the  urethra  from  hypertrophy  of  the  prostate  405 

120.  Vertical  elongation  of  the  urethra  from  hypertrophy  of  the  prostate  406 

121.  Sarcoma  of  the  median  portion  of  the  prostate             .             .             .  422 

122.  Prostatic  concretions      .......  426 

123.  Two  concentric  concretions  in  the  prostatic  ducts      .             .             .  427 

124.  Prostatic  calculus           .......  428 

125.  Linear  stricture  ........  455 

126.  Bridle  stricture  ........  455 

127.  Annular  stricture            .......  456 

128.  Indurated  annular  stricture       ......  456 

129.  Exploratory  bulbous  bougie      ......  463 

130.  Dilatation  of  the  uretliral)ehind  the  stricture  .             .             .             .  464 

131.  Urinary  cyst  consequent  upon  stricture  of  the  urethra           .             .  465 

132.  Narrow  stricture,  and  dilated  and  reticulated  membranous  and  pros- 

tatic portions  of  the  urethra  behind  it           ...             .  466 

133.  Eifects  of  stricture  on  the  urinary  organs        ....  468 

134.  Porte-canstique  ........  470 

135.  Otis's  urethrometer        .......  472 

136.  French  catheter  scale     .......  474 

137-140.  Gum-elastic  bougies            ......  474 

141.  Fihform  bougies              .             ......  476 

142.  Mercier's  catheter  for  avoiding  a  false  passage             .             .             .  476 

143.  Richardson's  tunnelled-handled  divulsor         ....  478 

144.  Conical  steel  bougie       .......  478 

145.  Bistouri -cache     .             .             ......  480 

146.  Gross's  urethrotome       .......  481 

147.  Civiale's  urethrotome     .......  481 

148.  Otis's  dilating  urethrotome        ......  483 

149.  Author's  urethrotome    .             ...             .             .             .             .  483 

150.  Trelat's  urethrotome       .......  483 

151.  Syme's  staft'        ........  484 


LIST    OF    ILLUSTRATIONS. 


FIG. 

152.  Gouley's  grooved  and  tuiinollcd  catheter  staff 

153.  Grooved  director  .... 

154.  Stricture  of  the  urethra,  with  false  passage;    enlar 

prostate  gland,  and  hypertrophy  of  the  bladder 

155.  Urinary  abscess  ..... 
15G.  Fistule  of  the  urethra     .... 

157.  Dieifeubach's  method  of  urethroplasty 

158.  Nelaton's  metliod  of  urethroplasty 

159.  Uretliroplasty  by  scrotal  flap    . 

160.  Polvpoid  fibroma  of  urethra 
IGl.  Pai)illoma  of  urethra      .... 
163.  Articulated  scoop  of  Bonnet 

163.  Hunter's  forceps  .... 

164.  Mathieu's  forceps  .... 
165-167.   Introduction  of  lithotrite  and  seizure  of  the  stone 

168.  Shot  perforation  of  the  urethra 

169.  Epispadias  ..... 

170.  Nelaton's  operation  for  epispadias 


of  the 


PAGE 

486 
487 

500 
511 
517 
523 
523 
524 
528 
531 
541 
541 
542 
542 
546 
561 
562 


DISEASES  OF  THE  URINARY  ORGANS. 


PAKT    I. 

DISEASES  AXD  INJURIES  OF  THE  BLADDER. 


CHAPTER    I. 

INFLAMMATION  OF  THE  BLADDER  AND  ITS  RESULTS. 

IxFLAMMATiox  of  the  bladder,  technically  termed  cystitis, 
generally  begins  in  the  mncous  membrane,  and  presents  itself 
under  two  varieties  of  form,  the  acute  and  clironic.  Of  these, 
tlic  first  is  exceedingly  infrequent,  while  the  chronic  form  of  the 
maladj',  on  the  contrary,  is  sufficiently  common,  and  often  entails 
a  vast  amount  of  suffering,  which,  continuing  for  months,  and 
perhaps  years,  finally  brings  the  patient  to  a  premature  grave. 

Some  modern  writers  subdivide  this  disease  as  it  aftects  one 
or  more  of  the  coats  of  the  bladder.  Thus,  when  the  serous 
covering  and  its  subjacent  tissue  are  alone  involved,  it  is  termed 
serous  cj^stitis,  or  epicystitis,  of  which  extremel}^  rare  occurrence 
it  need  only  be  said  that  it  is  nothing  more  than  a  circumscribed 
peritonitis,  resulting  from  extension  of  inflammation  from  the 
other  tissues,  or  appearing  as  a  metastatic  phenomenon  in  the 
course  of  pyemia,  typhus,  and  the  exanthemata,  and  liable  to  be 
attended  with  the  formation  of  abscesses,  which  open  into  the 
urethra,  the  bladder,  the  vagina,  or  the  rectum.  When  all  the 
coats  are  implicated,  it  is  termed  interstitial,  or  parenchymatous 
cystitis,  which  is  discussed  further  on  under  the  head  of  suppu- 
ration and  abscess  of  the  bladder.  Finally,  when  the  mucous 
membrane  and  submucous  connective  tissue  alone  participate  in 
the  morbid  action,  it  is  known  as  mucous  cystitis,  the  ordinary 
form  of  the  disease. 
2 


18  INFLAMMATIOX    OF    THE    BLADDER. 

Sect.  I.— ACUTE  INFLAMMATION. 

Acute  cystitis  usually  occurs  in  irregular,  circumscribed 
patches,  although  the  entire  mucous  membrane  may  be  invaded. 
Any  portion  of  the  organ  is  lialjle  to  sutter,  but  the  parts  most 
frequently  affected  are  the  neck  and  bas-fond.  During  its  pro- 
gress tlie  morl)id  action  often  spreads  from  the  mucous  membrane 
to  the  submucous  connective  tissue,  and  from  thence  to  the  mus- 
cular tunic.  The  peritoneal  investment  is  rarely  implicated,  in 
any  considerable  degree,  however  serious  the  attack. 

The  causes  of  acute  cystitis  are  the  imprudent  use  of  cantha- 
rides,  oil  of  turpentine,  nitrate  of  potassa,  and  other  stimulating 
articles ;  contusions  of  the  perineum  and  hypogastrium,  from 
blows,  kicks,  or  falls ;  the  extension  of  gonorrhoea,  and  inflam- 
mation of  the  prostate;  the  injection  of  irritating  fluids;  and 
the  rough  use  of  catheters,  bougies,  lithotrites,  and  sounds. 

Occasionally  it  is  traceable  to  the  effects  of  excessive  venery, 
and  to  inordinate  distention  of  the  bladder  from  neglect  to  void 
the  urine.  Sudden  transition  from  heat  to  cold,  and  the  repul- 
sion of  cutaneous  eruptions,  also  produce  acute  cystitis,  especially 
in  persons  of  a  gouty  and  rheumatic  habit.  But  the  most  fre- 
quent causes,  without  doubt,  are  wounds  of  the  bladder,  the 
presence  of  calculous  concretions,  rough  horseback  or  carriage 
exercise,  the  intemperate  use  of  stimulating  drinks,  and  injury 
sustained  during  parturition,  whether  from  the  pressure  of  the 
child's  head,  or  the  injudicious  use  of  instruments.  Finally, 
we  must  not  omit,  in  this  list  of  exciting  causes,  to  mention 
protracted  retention  of  altered  urine,  from  enlargement  of  the 
prostate,  stricture  of  the  urethra,  and  paralysis  of  the  organ, 
which,  it  is  well  known,  often  awakens  violent  and  even  fatal 
cystitis. 

Acute  cystitis  is  more  common  in  adults  than  in  children  and 
old  peo]^le,  in  the  strong  and  robust  than  the  weak  and  sickly, 
and  in  men  than  in  women.  It  also  occurs  more  frequently  in 
autumn  and  winter  tlian  in  spring  or  summer,  and  in  cold  than 
in  warm  climates.  Various  circumstances,  such  as  an  arthritic 
diathesis,  intemperarjce  in  eating  and  drinking,  and  j^ermanent 
obstacles  to  micturition,  predispose  to  its  development. 

The  minute  features  of  acute  inflammation  of  the  mucous 
membrane  of  the  bladder  are  hyperemia,  epithelial  hyperplasia, 


ACUTE    INFLAMMATION.  19 

and  thickening  of  the  subepithelial  connective  tissue,  as  indi- 
cated by  increased  vascularity,  the  discolored  patches  beino;  per- 
vaded by  fine  or  coarse  capillary  vessels,  and  exhibiting,  in  some 
cases,  points  of  ecchymosis,  loss  of  transparency,  softening,  and 
tumefaction,  with  alteration  of  the  natural  secretion.  At  the 
commencement  of  the  disease,  the  secretion  of  mucus  is  somewhat 
augmented  in  quantity,  but  thinner  and  less  viscid  than  in  the 
natural  state.  When  at  its  height  it  is  almost  entirely  sup- 
pressed, and  the  membrane  is  consequently  somewhat  dry  ;  but 
as  this  period  is  always  of  short  duration,  the  secretion  is  soon 
reestablished,  and  often  exists  in  great  abundance,  being  of  a 
thick,  ropy  consistence,  and  of  a  pale  straw,  grayish,  drab,  or 
greenish  color.  In  the  higher  grades  of  the  disease,  the  secre- 
tion, instead  of  being  mucous,  is  puriform  or  muco-purulent, 
and  tinged  with  blood,  which  seems  to  be  poured  out,  under 
these  circumstances,  in  the  form  of  an  exhalation,  though  occa- 
sionally it  is  no  doubt  caused  by  a  laceration  of  some  of  the 
capillary  vessels. 

In  violent  attacks,  the  inflammation  is  no  longer  limited  to 
the  mucous  and  other  tunics  of  the  bladder,  but  it  extends  to 
and  involves  the  surrounding  and  associated  organs.  The  parts 
which  are  more  particularly  liable  to  suffer  are  the  ureters  and 
the  prostate  gland.  Along  the  former  the  morbid  action  is  pro- 
pagated to  the  kidneys,  giving  rise  either  to  derangement  of  their 
functions,  or  pyelitis,  which  is  not  an  uncommon  cause  of  death. 
The  mucous  lining  of  the  ureters,  from  one  extremity  to  the 
other,  is  abnormally  red  and  turgid,  and  their  inferior  outlet  is 
sometimes  almost  obliterated,  or  choked  up  Avith  lymph,  mucus, 
or  pus,  or  by  all  these  fluids  variously  combined  with  each  other. 
The  prostate  gland  may  be  considerably  swollen,  especially  when 
the  disease  affects  the  neck  of  the  bladder,  and  thus  seriously 
complicate  tlie  primary  disorder,  by  increasing  the  local  dis- 
tress, and  serving  as  a  mechanical  obstacle  to  the  evacuation  of 
the  urine. 

Acute  cystitis  is  generally  ushered  in  by  bold  and  well-marked 
symptoms.  The  first  which  usually  attracts  attention  is  a  dull, 
obscure,  deep-seated  pain,  or  rather  a  sort  of  gnawing  uneasi- 
ness, in  the  region  of  the  bladder,  which,  rapidly  increasing 
in  intensity,  soon  extends  to  the  neighboring  organs.  At  this 
early  stage,  there  is  little  or  no  constitutional  disturbance ;  or, 


20  INFLAMMATION    OF    THE    BLADDER. 

if  there  be  any  disorder  of  tliis  kind,  it  is  manifested  by  slight 
chills  alternating  Avith  tinshes  of  heat,  some  thirst,  and  a  little 
excitement  of  the  pulse,  which  is,  perhaps,  somewhat  more  hard 
and  frequent  than  usual.  The  patient  now  begins  to  expe- 
rience frequent  calls  to  void  his  urine,  which  is  expelled  in 
small  quantities,  or  it  may  be  drop  by  drop,  accompanied  with 
violent  straining,  distressing  spasm,  and  a  peculiar  burning  or 
scalding  at  the  neck  of  the  bladder  and  along  the  course  of  the 
urethra.  The  hypogastrium  is  distended,  painful,  and  so  exqui- 
sitely tender  as  to  render  even  the  weight  of  the  bedclothes 
intolerable.  The  limbs  are  drawn  up,  and  the  body  bent 
forward,  to  relax  the  abdominal  muscles,  and  relieve  the  tension 
of  the  bladder.  As  the  disease  progresses,  the  desire  to  pass 
water  becomes  uncontrollable,  the  pain  in  the  bladder  assumes 
a  lancinating,  tearing,  or  throbbing  character,  and  the  small 
quantit}'  of  urine  which  dribbles  oif  is  thick,  ropy,  and  turbid, 
reddish,  or  tinged  with  blood.  The  pain  shoots  along  the 
testicles,  groins,  upper  part  of  the  thighs,  and  spermatic  cords, 
to  the  sacrolumbar  region,  where  it  is  often  almost  insupport- 
able. It  is  augmented  by  the  slightest  movement  of  the  body, 
by  pressure  and  percussion,  by  the  passage  of  the  contents  of  the 
bowels,  by  the  insertion  of  the  finger  into  the  rectum,  and  by 
the  introduction  of  the  catheter;  but  is  somewhat  relieved 
when  tlie  bladder  is  emptied  of  its  contents.  The  perineum 
feels  sore  to  the  touch,  and  there  is  incessant  vesical  tenesmus, 
accompanied  by  a  degree  of  straining,  or  bearing  down,  equal 
to  what  occurs  in  childbirth.  Notwithstanding  these  eflbrts 
at  micturition,  which  are  sometimes  almost  without  intermis- 
sion, the  urine,  never  being  entirely  expelled,  gradually  accu- 
mulates, and  the  bladder  at  length  ascends  above  the  pubes  into 
the  hypogastric  region,  forming  a  globular  and  elastic  tumor, 
exquisitely  sensitive  under  the  slightest  touch.  In  some  cases 
there  is,  almost  from  the  very  commencement,  a  constant  drib- 
bling of  urine,  while  in  others  there  is  complete  retention  of 
this  fluid. 

The  urine,  at  first  acid  and  of  normal  color,  soon  becomes 
alkaline  and  of  a  dirty  drab,  or  deep  red  hue,  from  its  admixture 
with  blood.  It  contains  mucus  and  epithelium,  and,  later  in  the 
disease,  flakes  of  lymph  and  pus,  which,  if  the  fluid  be  permitted 
to  remain  at  rest,  subside  to  the  bottom  of  the  receiver,  forming 


ACUTE    INFLAMMATION.  21 

a  ropy,  glntinoiis  mass,  equal  to  one-fifth,  one-foiirtli,  or  even 
one-third  of  the  entire  excretion. 

When  the  disease  is  fully  developed,  there  is  always  more  or 
less  constitutional  derangement,  as  indicated  by  the  quick,  hard, 
small,  and  frequent,  or  frequent  and  wiry  pulse ;  the  hot  and 
dry  skin  ;  the  coated  tongue  ;  the  impaired  appetite  ;  the  urgent 
thirst ;  the  constipation  of  the  bowels  ;  the  anxious  and  dejected 
countenance,  and  a  state  of  constant  restlessness  and  agitation. 
The  limbs  are  drawn  up  as  in  acute  enteritis,  and  there  is  gene- 
rally great  distress  in  the  anus  and  rectum,  from  an  extension  of 
the  inflammation.  IsTausea  and  vomiting,  with  severe  precordial 
oppression,  are  rarely  absent  in  this  stage  of  the  complaint,  and 
there  is  occasionally  complete  suppression  of  the  urine.  Towards 
the  close  of  the  disease,  the  surface  is  bathed  with  a  cold,  clammy 
perspiration,  and  exhales  a  peculiar  urinous  odor ;  the  mind 
wanders  ;  hiccup  supervenes  ;  the  strength  rapidly  declines  ;  the 
countenance  assumes  a  Hippoeratic  expression :  the  extremities 
become  cold  ;  and  the  patient  finally  sinks  into  a  state  of  coma, 
from  which  he  cannot  be  aroused. 

Some  diversity  occurs  in  the  symptoms  of  cystitis,  dependent 
upon  the  particular  seat  of  the  morbid  action.  When  the  neck 
of  the  bladder  is  mainly  aftected,  excessive  pain  and  a  sense  of 
weight  or  fulness  are  experienced  in  the  anus  and  perineum ; 
there  is  obstinate  retention  of  urine,  with  an  incessant  desire  to 
micturate ;  and  severe  scalding  or  burning  is  felt  along  the 
urethra,  from  one  extremity  of  it  to  the  other.  When  the 
anterior  wall  of  the  bladder  is  inflamed,  there  is  great  tenderness 
on  pressure  and  percussion,  with  a  sense  of  constriction,  in  the 
hypogastric  region ;  the  patient  lies  on  his  side,  and  the  knees 
are  partially  flexed,  to  prevent  tension  of  the  abdominal  muscles. 
There  is  likewise,  under  these  circumstances,  less  pain  about  the 
neck  of  the  bladder,  the  desire  to  micturate  is  not  so  frequent, 
and  the  water  can  be  retained  longer  and  better.  When  the 
inflammation  occupies  the  bas-fond  of  the  bladder,  the  rectum  is 
more  apt  to  sufler,  and  the  patient  is  harassed  with  constant 
straining  and  tenesmus. 

Acute  cj'stitis  usually  runs  its  course  with  considerable  rapidity. 
It  seldom  continues  beyond  the  sixth  or  eighth  day  without 
terminating  in  resolution,  tending  to  suppuration,  passing  into 
gangrene,  or  assuming  a  chronic  type.     When  the  malady  is 


22  INFLAMMATION    OF    THE    BLADDER. 

about  to  (leclino,  there  is  a  gradual  abatement  of  the  local  and 
eouf^titutional  symptoms;  but  a  sensation  of  numbness,  weight, 
or  uneasiness  usually  remains  in  the  affected  part  after  the  violence 
of  the  disease  has  subsided. 

The  prognosis  in  cystitis  depends  ui)on  the  various  circum- 
stances enumerated  among  the  exciting  causes,  and  the  possibility 
of  removiniJ-  them.  When  the  inflammation  is  limited,  the  con- 
stitution  sound,  and  the  fever  moderate,  the  disease  generally 
yields  very  readily  to  treatment,  and  may  even  disappear  of  its 
own  accord.  When  the  system  is  enfeebled  by  previous  suffer- 
ing, debauch,  or  intemperance,  death  is  apt  to  ensue  from  ure- 
mia, gangrene,  or  pyemia. 

The  treatment  of  acute  cystitis  is  directed,  first,  to  subduing 
constitutional  excitement ;  and,  secondly,  to  allaying  local  irri- 
tation. For  accomplishing  the  first  of  these  ends,  the  remedies 
mainly  relied  upon,  in  the  earlier  stages  of  the  complaint,  are 
general  and  topical  bleeding,  cathartics,  and  diaphoretics,  aided 
by  an  antiphlogistic  regimen.  Promptly  and  vigoroush'  em- 
ployed, there  are  few  cases  of  acute  cystitis  which  resist  these 
means  beyond  the  second  or  third  day,  and  such  as  do  are  always 
moi-e  easily  managed  afterwards  by  mild  treatment.  I  have 
repeatedly  cut  short,  b}'  the  lancet  alone,  attacks  of  this  disease 
so  severe  as  to  leave  the  patient  no  rest,  and  so  threatening  as 
to  induce  the  Avorst  apprehensions  for  his  ultimate  recovery. 

There  is  a  variety  of  cystitis,  properly  denominated  acute,  as 
it  respects  the  local  distress,  in  which  there  is  an  entire  absence 
of  constitutional  disturbance,  and  yet  the  suffering  is  exceed- 
ingly severe.  In  these  cases  there  is  no  remedy,  according  to 
my  experience,  which  is  followed  by  such  prompt  and  permanent 
relief  as  copious  bleeding  at  the  arm.  The  operation  rarely  re- 
quires to  be  repeated,  and  is  generally  sufficient,  with  the  aid  of 
a  general  laxative  and  a  dose  of  Dover's  powder,  to  effect  a  cure 
in  thirty-six  or  forty-eight  hours;  sometimes,  indeed,  much 
sooner. 

The  bowels  demand  early  attention,  especially  if  they  are  over- 
loaded with  fecal  matter,  the  pressure  of  which  would  prove 
injurious  to  the  inflamed  and  suffering  organ.  Where  there  is 
no  marked  derangement  of  the  biliary  secretion,  the  best  purga- 
tive is  castor  oil,  or  sul^Jiate  of  magnesia,  aided  by  an  enema  of 
cool  water,  thin  gruel,  or  soapsuds.     If  an  opposite  condition 


ACUTE    INFLAMMATION.  23 

exist,  a  dose  of  calomel  should  be  given,  either  alone,  or,  in 
urgent  cases,  in  union  with  rhubarb  and  jalap.  Under  no  cir- 
cumstances is  it  proper  to  administer  medicines  calculated  to 
irritate  the  lower  bowel,  and,  through  it,  the  urinary  bladder. 

As  soon  as  proper  depletion  has  been  practised,  and  the  ali- 
mentar\"  canal  well  cleared  out,  diaphoretics  are  indicated,  the 
one  which  I  have  found  most  useful  being  the  tratrate  of  anti- 
mony and  potassa,  in  the  form  of  the  antimonial  and  saline 
mixture,  of  which  the  dose  is  a  tahlespoonful  every  two,  three, 
or  four  hours.^  This  seldom  fails  to  produce  copious  diaphore- 
sis, to  allay  vascular  excitement,  to  calm  the  affected  organ,  and 
to  keep  the  bowels  in  a  soluble  condition.  Where  the  skin  is 
already  soft,  or  where  a  diaphoretic  and  opiate  are  required, 
nothing  is  so  beneficial  as  Dover's  powder,  in  doses  of  five  grains, 
with  the  sixth  of  a  grain  of  morphia,  three  or  four  times  in  the 
twenty-four  hours.  If  the  stomach  is  irritable,  the  effervescing 
draught  is  preferable  to  anything  else. 

The  action  of  the  above  medicines  may  be  favored  by  tepid 
drinks,  the  warm  bath,  and  hot  fomentations.  The  best  drinks 
are  such  as  are  somewhat  demulcent,  as  gum  Arabic  water,  slip- 
per}^ elm  water,  rice  water,  or  flaxseed  tea,  rendered  palatable 
b}'  the  addition  of  a  little  lemon  juice,  citrate  of  potassa,  or  the 
neutral  mixture.  In  the  use  of  these  and  similar  articles,  care 
must  be  taken  not  to  allow  the  patient  to  indulge  so  freely  as  to 
run  the  risk  of  producing  too  great  a  flow  of  urine ;  the  object 
should  be  merely  to  allay  the  acrimony  of  tliis  fluid,  and  to 
render  it  more  acceptable,  so  to  speak,  to  the  suffering  organ. 

Diuretics,  strictly  so  called,  are  improper  in  this  affection,  and 
should,  therefore,  be  avoided.  When  the  urine  is  acrid,  high- 
colored,  or  very  scanty,  a  small  quantity  of  nitrate  of  potassa,  or 
spirit  of  nitrous  ether,  mixed  with  some  demulcent  fluid,  may, 
under  such  circumstances,  be  given  to  modify  the  renal  secre- 
tion, and  allay  vesical  irritation.  In  the  gouty  and  rheumatic 
forms  of  the  malady,  colchicum,  combined  with  morphia,  is 
sometimes  beneficial.     In  the  later  stages  of  the  disease,  an  infu- 

,  '  The  combination,  which  I  am  in  the  habit  of  using  in  this  and  other  forms 
of  inflammation,  consists  of  two  grains  and  a  half  of  tartrate  of  antimony,  two 
ounces  of  sulphate  of  magnesia,  two  grains  of  sulphate  of  morpliia,  a  drachm 
and  a  half  of  tincture  of  veratrum  viride,  half  a  drachm  of  aromatic  sulphuric 
acid,  two  ounces  of  sjrup  of  ginger,  aud  tea  ounces  of  water. 


24  INFLAMMATION    OF    THE    BLADDER. 

sion  of  11  va  iirsi  aiul  Imps,  in  the  proportion  of  one  ounce  and  a 
half  of  the  former,  and  lialf  an  ounce  of  the  latter  to  the  quart 
of  water,  often  acts  like  a  charm  in  the  lighter  grades  of  C3'stitis, 
in  allaying  pain  and  spasm  at  the  neck  of  tlie  bladder.  An  ordi- 
nary sized  wineglassful  of  this  should  be  given  five  or  six  times 
a  day,  either  alone,  or  in  combination  -with  morphia  and  citrate 
of  potassa  or  bromide  of  potassium,  or  the  latter  articles  and 
balsam  of  copaiba. 

Among  the  more  important  local  remedies  for  arresting  cys- 
titis, and  tranquillizing  the  affected  organ,  are,  leeching  and 
cupping,  anodyne  enemata,  fomentations,  and  the  hip-bath. 

For  an  adult,  in  ordinary  cases,  fifteen  or  twenty  foreign 
leeches  applied  to  the  perineum  and  verge  of  the  anus,  to  the  upper 
and  inner  part  of  the  thigh,  or  when  the  summit  of  the  bladder 
is  affected,  to  the  hypogastrium,  will  rarely  disappoint  expecta- 
tion. The  pain  and  distress  in  the  back,  which  often  constitute  a 
source  of  so  much  suffering,  are  usually  promptly  relieved  by 
the  application  of  cups,  either  dry  or  wet,  to  the  sacrolumltar 
region. 

Of  all  the  local  remedies  none  hold  a  higher  rank  in  the  treat- 
ment of  this  affection  than  anodynes,  administered  by  the  rectum, 
either  in  the  form  of  injections,  or  in  that  of  suppositories. 
They  not  only  allay  pain  and  spasm,  but  they  quiet  the  bladder, 
and  render  it  more  able  to  bear  the  presence  of  the  urine,  a  de- 
sire to  pass  which  is  a  principal  cause  of  the  patient's  suffering. 
The  best  form  of  injection,  for  an  adult,  is  from  half  a  drachm 
to  a  drachm  and  a  half  of  laudanum  to  two  ounces  of  tepid 
water,  thrown  up  with  a  vulcanized  syringe,  with  a  long  nozzle, 
which  is  far  preferable  to  all  the  patent  contrivances  of  the  kind 
of  which  I  hfive  any  knowledge.  The  bowel  should  be  pre- 
viously cleared  out  with  a  purgative,  or  an  enema,  and  care 
should  be  taken  not  to  force  the  fluid  against  the  anterior  wall 
of  the  rectum.  The  best  suppository  is  poAvdered  opium,  from 
two  to  four  grains,  thoroughly  mixed  with  cocoa  butter,. and 
introduced  upon  the  end  of  the  forefinger,  well  oiled. 

As  auxiliary  remedies,  in  the  treatment  of  this  disease,  men- 
tion may  be  here  made  of  fomentations  with  flannel  wrung  out 
of  hot  water,  either  simple,  or  medicated  with  laudanum,  lauda- 
num and  camphor,  poppies,  or  ho])S.  To  prevent  evaporation, 
and  confine  the  heat,  the  surface  of  the  flannel  should  be  covered 


ACUTE    INFLAMMATION.  25 

Avitli  a  piece  of  oiled  silk.  Instead  of  fomentations,  dry  heat, 
applied  to  the  hypogastrium  and  perineum  by  means  of  an  India- 
rubber  bag  of  special  construction,  filled  with  hot  water,  is  ex- 
ceedingly grateful  to  the  affected  part,  as  well  as  to  the  general 
system. 

The  warm  hip-bath,  or  immersion  of  the  entire  body  in  warm 
water,  is  sometimes  eminently  serviceable  in  relieving  the  local 
suffering,  and  exciting  the  cutaneous  emunctories.  Generally 
speaking,  the  latter  is  to  be  preferred  to  the  former,  on  account 
of  the  greater  convenience  and  less  fatigue  which  attend  its 
administration,  as  well  as  the  more  thorough  relaxation  of  the 
system.  The  temperature  of  the  water  should  range  from  85° 
to  92°,  and  the  immersion  should  be  continued  from  twenty 
minutes  to  an  hour,  according  to  the  effects  of  the  remedy,  which 
should  alwa^'s  be  carefully  noted. 

The  exciting  causes  of  this  disease  lead  to  certain  modifications 
of  the  treatment,  which  should  be  well  understood  by  the  prac- 
titioner. The  principal  circumstances  which  require  to  be  con- 
sidered in  this  relation  are  urinary  concretions  and  other  foreign 
bodies,  the  use  of  cantharides,  the  extension  of  gonorrhoeal  in- 
flammation, the  repulsion  of  gout,  rheumatism,  and  cutaneous 
eruptions,  stricture  of  the  urethra,  and  enlargement  of  the  pros- 
tate gland. 

The  treatment  of  cystitis,  dependent  upon  the  presence  of  a 
calculus,  is  to  be  conducted  upon  general  principles ;  no  effort 
should  be  made  to  extract  the  foreign  body,  much  less  to  crush 
it,  until  the  inflammation  is  subdued.  The  case  is  different 
when  the  cystitis  has  been  induced  by  the  presence  of  a  foreign 
substance  which  has  penetrated  the  bladder  from  without,  as  a 
splinter,  or  piece  of  bone.  Here  the  first  object  should  be  to 
remove  the  extraneous  body  as  early  as  possible,  on  the  well- 
known  principle  that  the  disease  induced  by  it  cannot  be  cured 
so  long  as  it  remains  in  contact  with  the  affected  viscus. 

Cystitis,  caused  by  the  absorption,  or  internal  use  of  cantha- 
rides, requires  a  treatment  somewhat  peculiar.  This  variet}^  of 
inflammation,  technically  called  strangury,  is  induced  by  the 
specific  action  of  cantharidin  upon  the  neck  of  the  bladder, 
terminating  in  a  constant  desire  to  pass  water,  accompanied  with 
excessive  pain  and  spasm  at  the  neck  of  the  organ,  horrible 
scalding  along  the  urethra,  and  sometimes  the  discharge  of  frag- 


26  INFLAMMATION    OF    THE    BLADDER. 

ments  of  fibrinous  exudation,  along  with  priapism.  The  symp- 
toms are  generally  urgent,  coming  on  within  the  first  twenty- 
four  hours,  and,  therefore,  require  prompt  and  vigorous  inter- 
ference. A  large  emollient  poultice  is  applied  to  the  vesicated 
surface,  hot  cloths  are  laid  upon  the  abdomen,  the  perineum, 
and  the  genitals,  and  a  drachm  of  laudanum,  mixed  with  two 
ounces  of  tepid  water,  is  injected  into  the  lower  bowel.  Demul- 
cent drinks,  with  sjurit  of  nitrous  ether,  or  liquor  potassse,  are 
freely  taken;  and,  in  severe  cases,  a  full  anodyne  is  exhibited  by 
the  mouth.  A  popular  remedy,  of  great  value  in  this  affection, 
especially  in  its  milder  forms,  is  a  decoction  of  parsley  root  and 
watermelon  seeds.  It  should  be  used  as  freely  as  the  stomach 
■will  bear,  either  alone,  or  in  combination  with  spirit  of  nitre 
and  paregoric.  There  are  few  case^  of  strangury  which  resist 
these  means,  or  which  require  more  active  treatment,  as  bleed- 
ing, purging,  diaphoretics,  and  the  warm  bath. 

Cystitis,  occasioned  by  an  extension  of  gonorrhoea,  usually 
after  the  third  week  of  its  existence,  is  characterized  by  severe 
tenesmus,  a  frequent  desire  to  micturate,  and  great  pain  in  pass- 
ing the  last  drops  of  urine,  which  is  sometimes  tinged  with 
blood.  The  inflammation,  which  may  occur  at  any  period  of 
the  specific  disease,  is,  in  great  measure,  confined  to  the  neck  6{ 
the  bladder,  and  rarely  assumes  a  violent  character.  The  treat- 
ment is  antiphlogistic,  aided  by  the  internal  exhibition  of 
copaiba,  and  the  use  of  anodyne  enemata. 

When  cystitis  depends  upon  a  gout}'  or  rheumatic  state  of  the 
constitution,  or  upon  a  retrocession  of  these  diseases,  colchicum 
is  indicated,  and  ought  to  be  conjoined  with  other  anti})hlogistic 
means.  One  full  dose,  given  at  bedtime,  is  preferable  to  small 
ones,  frequently  repeated.  Another  valuable  remedy  in  this 
variety  of  cystitis  is  calomel,  administered  with  a  view  to  its 
constitutional  eftects.  In  obstinate  cases  of  this  kind,  it  is,  in 
fact,  almost  indispensable.  It  may  be  given,  three  or  four  times 
a  day,  in  doses  of  two  grains,  combined  with  half  a  grain  of 
opium,  to  prevent  it  from  acting  too  freely  upon  the  bowels, 
and  aid  in  procuring  sleep.  As  soon  as  the  gums  become  tender, 
the  mercury  is  discontinued,  or  administered  in  smaller  quantity 
or  at  longer  intervals. 

When  the  malady  has  been  induced  by  the  sudden  repulsion 
of  some  cutaneous  disease,  as  herpes,  urticaria,  or  erysipelas,  the 


CROUPOUS  INFLAMMATION  OF  THE  BLADDER.    27 

indication  is  to  reinvite  the  disease  to  its  former  situation,  bj 
the  application  of  blisters,  and  the  exhibition  of  such  means  as 
the  state  of  the  system  may  seem  to  require. 

When  the  cystitis  is  complicated  with,  or  dependent  upon, 
stricture,  or  enlargement  of  the  prostate  gland,  the  treatment 
must  be  of  a  mixed  character ;  an  attempt  being  made,  while 
we  endeavor  to  cure  the  vesical  symptoms,  to  relieve  the  pre- 
dxistent  affection. 

Finally,  should  retention  of  urine  occur,  no  time  is  to  be  lost 
in  having  recourse  to  the  gum-elastic  catheter.  This  accident 
often  ensues  at  an  early  stage  of  the  disease,  and  always  requires 
the  closest  vigilance  on  the  part  of  the  surgeon  ;  for  the  accumu- 
lated fluid  not  only  acts  injuriously  by  distending  the  coats  of 
the  bladder,  already  crippled  and  enfeebled  in  consequence  of  the 
inflamed  condition  of  its  muscular  fibres,  but  by  undergoing 
speedy  decomposition,  whereby  it  becomes  a  source  of  direct 
mischief  to  the  lining  membrane.  To  prevent  these  evils,  the 
catheter  should  be  used  every  six  or  eight  hours,  or  whenever, 
indeed,  there  is  the  slightest  tendency  to  distention,  care  being 
always  taken  to  Avithdraw  it  as  soon  as  the  urine  has  been 
evacuated. 

Sect.  II.— CROUPOUS  INFLAMMATION  OF  THE  BLADDER. 

The  mucous  membrane  of  the  bladder,  like  that  of  the  alimen- 
tary and  aerial  canals,  is  liable  to  a  form  of  inflammation,  variously 
termed  croupous,  diphtheritic,  fibrinous,  plastic,  exudative,  and 
pseudomembranous.  The  term  croupous,  retained  on  the  present 
occasion,  includes  that  and  the  diphtheritic  process,  between 
wdiich  there  are  certain  differences.  In  the  former,  the  inflam- 
matory new  material,  composed  of  a  mass  of  germinal  and  meta- 
morphosed epithelial  cells  and  fibrin,  is  attached  to  the  surface 
of  the  mucous  membrane,  where  it  may  be  found,  in  rare  instances, 
on  dissection,  as  a  mould  of  the  interior  of  the  viscus.  Such  casts, 
which  are  usually  covered  with  phosphatic  deposits,  give  rise  to 
retention  of  urine,  and  may  even  be  expelled  during  life,  when 
the}'  are  mistaken  for  exfoliations  of  the  lining  membrane,  or 
even  for  the  placenta,  as  has  occurred  in  parturient  females.  In 
the  diphtheritic  variety  of  the  aft'ection,  on  the  other  hand,  in 
which  the  pathological  change  consists  in  infiltration  of  the  sub- 


28  INFLAMMATION    OF    THE    BLADDER. 

epithelial  connective  tissue  with  germinal  cells,  and  which,  there 
fore,  does  not  show  itself  as  a  deposit,  the  infiltrated  mucous 
membrane  may  be  thrown  off  in  the  form  of  a  complete  cast  of 
the  bladder,  as  in  the  remarkable  instances  recorded  by  Luschka,^ 
and  Mr.  Spencer  Wells.^  In  the  case  of  a  malingering  female, 
under  tlie  charge  of  ^fr.  Maunder,^  the  supposed  exfoliated  mu- 
cous membrane  turned  out  to  be  a  bladder  from  one  of  the  lower 
animals. 

Croupous  inflammation  is  exceedingly  rare  as  an  idiopathic 
affection  ;  but  occasionally  occurs  in  association  with  the  same 
disease  elsewhere.  As  a  secondary  affection,  it  is  met  with  in 
cholera,  typhus,  the  exanthemata,  and  p^'cmia,  and  as  a  result 
of  direct  violence,  and  the  irritation  produced  by  decomposing 
urine,  carcinoma,  calculi,  and  foreign  bodies.  The  presence  of 
a  pseudomembrane,  of  a  quarter  to  half  a  line  in  thickness,  is  a 
characteristic  feature  of  cystitis  produced  by  cantharides.  The 
exudation  is  not  peculiar  to  any  age  or  sex,  and  is  most  common 
in  the  neck  or  bas-fondof  the  organ,  although  no  part  is  entirely 
exempt  from  it.  Generally  speaking,  it  is  of  a  grayish  or  drab 
color,  but  now  and  then  dark  brown,  greenish,  or  even  reddish 
from  an  admixture  of  the  coloring  matter  of  the  blood ;  while 
it  varies  in  consistence  from  a  thin  solution  of  arrowroot  to  that 
of  tlie  huffy  coat  of  the  blood.  The  deposit,  or  infiltration, 
rarely  presents  itself  as  a  distinct  membrane,  spread  over  the 
entire  inner  surface  of  the  bladder ;  but,  in  most  cases,  it  occurs 
in  patches  from  half  an  inch  to  two  inches  in  diameter ;  or  it 
may  present  itself  in  the  form  of  small  dots  ;  or  as  an  amorphous 
mass  of  a  dirty  grayish  color. 

When  flakes  of  aplastic  lymph,  or  false  membranes,  are  de- 
posited in  large  quantities,  the}'  necessarily  diminish  the  capacity 
of  the  bladder,  and  seriously  embarrass  its  functions.  Extending 
into  the  urethra,  they  may  choke  up  that  passage,  and  thus 
impede  the  flow  of  urine  ;  and  I  have  several  times  seen  complete 
retention  ensue  from  this  cause.  Prolonged  upwards  into  the 
ureters,  the  deposit  interferes  with  the  excretion  of  urine,  and 
leads  to  a  fatal  result  from  uremia.     Fortunately,  however,  in 

1  Virchow's  Arcliiv,  Bd.  vii.  p.  30. 

2  Trans.  Path.  Soc.  London,  vol.  xv.  p.  141. 
^  Ibid.,  vol.  xiii.  p.  150. 


SUPPURATION    AND    ABSCESS    OF    THE    BLADDER.        29 

most  cases,  it  is  discharged  almost  as  fiist  as  it  is  formed,  and 
thus  the  evil  consequences  alluded  to  are  prevented. 

There  are  no  symptoms  by  which  this  form  of  inflammation  is 
distinguishable  from  ordinary  cystitis,  save  the  presence  of  some 
of  the  exuded  matter,  loosened  by  the  production  of  pus,  in  the 
urine,  or  at  the  orifice  of  the  urethra.  The  treatment,  in  addi- 
tion to  the  remedies  employed  for  cystitis,  consists  in  relieving 
the  bladder  with  the  catheter,  and  preventing  reaccumulation 
by  injections  of  a  solution  of  nitrate  of  silver,  in  the  proportion 
of  from  four  to  ten  grains  of  the  salt  to  the  ounce  of  water. 
When  there  is  reason  to  believe,  from  the  nature  of  the  case, 
that  the  bladder  is  nearly  filled  with  the  exudation,  the  proper 
proceeding  is  to  open  it  above  the  pubes  and  turn  out  its  con- 
tents. In  this  wa}',  a  cyst,  of  the  shape  and  dimensions  of  the 
interior  of  the  viscus,  is  said  by  Dr.  Knox^  to  have  been 
removed  by  Mr.  Liston. 

Sect.  III.— SUPPURATION  AND  ABSCESS  OF  THE  BLADDER. 

A  discharge  of  pus,  or  muco-purulent  fluid,  from  the  lining 
membrane  of  the  bladder,  although  sufliciently  common  in  con- 
nection with  chronic  cystitis,  is  infrequent  as  a  consequence  of 
the  acute  form  of  the  disease.  The  discharge,  moreover,  is 
usually  of  brief  continuance,  and  small  in  quantity,  Avhile  in 
chronic  cystitis  it  often  lasts  for  a  long  time,  and  is  occasionally 
astonishingly  profuse. 

The  matter,  instead  of  being  secreted  l)y  the  free  surface  of  the 
mucous  membrane,  occasionally  presents  itself  in  the  form  of  an 
abscess,  situated  in  the  submucous  connective  tissue,  or  between 
the  muscular  and  serous  tunics.  Abscesses  forming  between 
the  coats  of  the  bladder  cannot,  from  the  nature  of  their  situa- 
tion, attain  much  volume,  and  we  accordingly  find  that  they 
are  seldom  larger  than  a  pea,  filbert,  or  a  pigeon's  egg.  The 
exceptions  in  which  they  acquire  the  magnitude  of  a  walnut,  a 
billiard-ball,  or  an  orange,  are  exceedingly  rare.  They  may 
occur  in  any  part  of  the  viscus,  but  are  most  frequently  observed 
at  its  neck ;  and  it  is  seldom  that  there  is  more  than  one, 
though  occasionally  as  many  as  five  or  six  have  been  met  with 

"  Medical  Times  and  Gazette,  Aug.  2,  1862,  p.  104. 


30  IXFLAMMATIOX    OF    THE    BLADDER. 

in  the  same  individual.  After  having  existed  for  an  indefinite 
period,  the  abscess  makes  an  attempt  to  evacuate  its  contents, 
by  exciting  ulcerative  absorption  of  the  parts  by  which  it  is 
covered. 

In  the  great  majority  of  instances,  the  abscess  points  inwards 
towards  the  cavity  of  the  bhiddcr,  into  which  it  finally  escapes 
and  passes  off  along  with  the  urine.  Such  a  termination  is 
necessarily  attended  by  a  sloughy,  ragged  state  of  the  mucous 
membrane,  which  may  be  so  undermined  by  the  ulcerative 
process,  as  to  eventuate  in  perforation,  with  infiltration  of  pus 
into  the  surrounding  tissues.  It  may  also  open  into  the  rectum, 
the  sigmoid  fiexure,  the  ileum,  the  vagina,  or  the  belly,  or 
through  tlie  abdominal  walls  above  the  pubes. 

The  matter,  instead  of  being  collected  into  an  abscess,  is  some- 
times diffused  through  the  connective  tissue  of  the  coats  of  the 
bladder,  which,  in  consequence,  exhibit  a  soft  o^dematous  aspect, 
and  pit  under  pressure.  Upon  puncturing  the  affected  part,  at 
different  points,  the  pent-up  fluid  escapes  as  from  an  anasarcous 
limb,  especially  if  it  be  intermixed  with  serum,  and  the  swelling 
proportionately  subsides.  This  form  of  suppuration,  of  which 
interesting  exan)ples  are  recorded  by  Bonnetus,'  Ruysch,-  and 
other  observers,  may  take  place  under  the  influence  of  calcu- 
lous irritation,  or  as  a  consequence  of  external  violence,  wdiich, 
in  fact,  is  its  most  frequent  cause.  The  occurrence  is,  of  course, 
very  rare. 

Suppuration  of  the  bladder  may  be  the  result  of  idiopathic 
inflanimation,  either  acute  or  chronic,  the  extension  of -gonor- 
rhoeal  inflammation,  retention  of  urine  from  stricture  or  enlarged 
prostate,  external  violence,  or  the  jiresence  of  some  foreign  body, 
as  a  calculus,  a  bougie,  or  a  catheter.  In  the  latter  case, 
abscesses  are  generally  produced  under  the  influence  of  pro- 
tracted irritation,  operating  directly  upon  the  tunics  of  the 
organ.  Occasionally  there  is  reason  to  believe  that  they  are 
developed  in  consequence  of  tlie  irritation  of  some  neighboring 
or  associated  viscus,  aa  the  ureter,  kidney,  prostate  gland,  or 
uterus.  The  purulent  collections  which  are  sometimes  found 
between  the  coats  of  the  bladder,  after  the  operation  of  litho- 
tomy, probably  have  their  origin  in  jDhlebitis. 

'  Sepulch.  Anat.,  t.  xi.  lib.  3,  p.  590.         «  Obs.  Anat.-Chir.,  ob.  89,  p.  82. 


SUPPURATION"    AND    ABSCESS    OF    THE    BLADDER.        31 

The  occurrence  of  suppuration  is  denoted  by  frequent  rigors, 
alternatino-  with  fluslies  of  heat ;  by.  an  increase  of  thirst,  anxiety 
and  restlessness ;  by  nausea  and  vomiting ;  by  the  character  of 
the  pain,  wliich  is  dull,  aching,  and  throbbing  ;  and  by  a  feeling 
of  weight  in  the  perineum  and  anus.  The  mind  generally 
wanders,  and,  in  many  cases,  there  is  confirmed  delirium.  As 
the  fever  declines,  the  urine  is  secreted  more  abundantly,  and 
exhibits  a  peculiar  whitish  appearance  indicative  of  the  presence 
of  pus.  In  abscess,  before  the  rupture  of  the  inclosing  cyst,  no 
such  evidence  is  discernible. 

The  diagnosis  of  sup})arative  cj'stitis  is  obscure,  even  the 
appearance  of  pus  in  the  urine  affording  no  conclusive  evidence 
of  its  occurrence,  as  it  may  have  been  derived  from  the  urethra, 
prostate,  ureter,  or  kidney.  The  nature  of  the  discharge  can 
always  be  determined  by  the  eye,  aided,  in  cases  of  doubt,  by 
the  microscope  and  the  guaiacum  test  of  Dr.  Day.  Infiltration 
of  pus  into  the  coats  of  the  bladder  cannot  be  distinguished 
during  life.  In  the  case  of  abscess  the  thickened  and  rigid 
bladder  is  incapable  of  muscular  movements.  Hence,  as  it 
cannot  expel  its  contents,  there  is  retention;  and  as  it  cannot 
expand,  the  urine  flowing  into  it  must  finally  escape  from  the 
urethra  drop  by  drop,  with  signs  of  violent  tenesmus.  If  seated 
at  the  neck  of  the  organ,  it  will  obstruct  the  orifice  of  the 
urethra ;  or  if  it  arise  in  the  vicinity  of  the  ureters,  it  will  com- 
press their  openings  and  cause  enormous  dilatation  of  these 
ducts.  Percussion  and  palpation  of  the  hypogastrium,  the 
rectum,  and  vagina,  especially  if  the  bladder  be  emptied  of  its 
urine,  may  lead  to  the  detection  of  a  tender,  and  possibly  fluctu- 
ating, tumor,  and  presumptive  evidence  of  the  existence  of  an 
abscess  is  aflbrded  Ijy  the  sudden  appearance  in  the  urine  of  a 
large  quantit}'  of  pus,  after  a  violent  effort  at  micturition,  or  an 
attempt  to  draw  off"  that  fluid.  Even  here,  however,  it  should 
not  l>e  forgotten  that  the  tumor  may  be  a  pericystic  accumu- 
lation of  pus,  and  that  the  matter  may  be  derived  from  an  ab- 
scess of  the  prostate,  kidney,  bowel,  or  uterus. 

The  prognosis  of  suppuration  of  the  mucous  membrane  of  the 
bladder  is  usually  favorable,  especially  when  it  is  an  effect  of  the 
acute  form  of  the  disease.  Suppuration,  dependent  upon  chronic 
inflammation,  often  persists  for  along  time,  obstinately  resisting 
every  method  of  treatment  that  can  be  brought  to  bear  against 


32  INFLAMMATION    OF    THE    BLADDER. 

it.  When  produced  bj  external  violence,  the  discharge  may  be 
so  copious  as  to  bring  on  hectic  fever,  with  all  its  train  of  evils. 
In  calculous  disease,  the  supi)uration  usually  disappears  promptly 
after  the  removal  of  the  exciting  cause. 

In  abscess  the  prognosis  is,  in  general,  not  favorable.  Recovery 
is  more  likely  to  take  place  when  the  disorder  is  the  result  of  ex- 
ternal violence  than  when  it  is  the  etfect  of  some  internal  cause. 
In  calculous  patients,  the  prognosis  is  unfavorable,  because  ab- 
scess after  abscess  is  lial)le  to  form,  until  the  patient's  strength 
is  undermined  by  local  and  constitutional  sutlering,  or  liis  life 
is  destroyed  by  total  suppression  of  urine. 

The  treatment  of  suppurative  inflammation  of  the  bladder  is 
to  be  conducted  upon  general  antiphlogistic  principles,  in  its 
early  stages,  and,  subsequently,  upon  the  tonic  and  invigorating 
plan,  aided  by  mildly  astringent  injections.  When  hectic  irri- 
tation is  present,  the  best  remedies  are  quinia  and  elixir  of  vitriol, 
in  doses  proportioned  to  the  age  and  condition  of  the  patient. 
The  diet  must  be  bland  and  nourishing;  demulcent  drinks  must 
be  freely  used,  to  obtund  the  acrimony  of  the  urine ;  and  the 
bowels  must  be  maintained  in  a  soluble  state,  by  Epsom  salt 
or  hot  enemata.  All  local  sources  of  irritation  must  be  removed 
as  early  as  possible ;  the  catheter  is  used,  if  necessary,  for  the 
relief  of  retention ;  spasm  of  the  bladder  is  allayed  by  anodyne 
suppositories,  opiate  injections,  and  fomentations  to  the  perineum 
and  hypogastrium ;  and  sleep  is  procured  hv  the  internal  exliibi- 
tion  of  opium,  the  salts  of  morphia,  or  black  drop.  If  abscesses 
point,  they  must  be  opened  witli  the  knife,  or  trocar,  and  free 
drainage  alforded. 

Sect.  IV.— GAXGRENE  OF  THE  BLADDER. 

Acute  inflammation  of  the  bladder  sometimes  terminates  in 
gangrene,  an  occurrence  which  is  particularly  to  be  apprehended 
when  the  morbid  action  is  marked  by  great  violence,  when  it  has 
been  induced  by  external  injur}-,  and  when  it  occurs  in  old,  in- 
firm, broken-down  sul^jects,  or  in  persons  whose  health  has  been 
much  impaired  by  previous  suftering.  Sometimes  it  succeeds  to 
an  attack  of  acute  inflammation  engrafted  upon  a  chronic  one. 

Although  mortification  may  occur  as  a  consequence  of  idio- 
pathic inflammation,  it   is   almost  always  the  result  of   over- 


GANGEENE  OF  THE  BLADDER.  33 

distention  from  urine,  of  external  violence,  or  of  compression  of 
the  cliild's  head  in  parturition.  Excessive  distention  from  pro- 
tracted retention  of  urine  is  often  followed  by  extensive  gangrene, 
whether  it  be  preceded  by  acute  inilammation  or  not.  The  whole 
organ  may  be  deprived  of  its  vitality  ;  but,  in  general,  the  gan- 
grene occurs  in  small,  circumscribed  spots  at  the  neck  of  the 
viscus.  The  aftection  occasionally  follows  the  operation  of 
lithotomy,  and  laceration  of  the  mucous  membrane  consequent 
upon  the  emploj-ment  of  instruments.  From  this  cause  many 
patients  have  perished  since  the  introduction  of  lithotrity.  It 
has  also  been  observed  by  Cossy,  in  an  epidemic  form,  in  persons 
laboring  under  typhoid  fever. 

The  period  which  intervenes  between  the  development  of 
cystitis  and  the  occurrence  of  gangrene,  varies  in  ditierent  cases 
and  under  ditferent  circumstances.  In  general,  it  does  not  exceed 
six  or  eight  da3's ;  but  it  may  be  considerably  shorter,  and,  on 
the  other  hand,  it  is  sometimes  delayed  to  the  end  of  the  second 
or  the  middle  of  the  third  week.  In  traumatic  cases,  gangrene 
often  occurs  at  an  early  stage  of  the  disease,  and  speedily  destroys 
the  patient. 

The  occurrence  of  mortification  of  the  bladder  is  announced  by 
great  prostration  of  strength;  sudden  cessation  of  pain;  coldness 
of  the  extremities ;  small,  weak,  and  frequent  pulse ;  profuse, 
clammy,  and  offensive  perspiration  ;  cadaverous  expression  of  the 
countenance  ;  mental  confusion,  delirium,  and  coma ;  hiccup ; 
twitching  of  the  tendons  ;  and,  towards  the  close,  by  colliquative 
diarrhoea,  and  involuntary  discharge  of  the  feces.  The  urine  is 
of  a  brownish  or  blackish  color,  emits  a  peculiarly  fetid  or 
cadaverous  odor,  and  is  etfectuall}'  retained  by  the  dead,  crippled, 
or  paralyzed  organ. 

On  dissection,  the  mucous  membrane  is  found  to  be  of  a  dark 
red,  livid,  or  purple  complexion,  very  soft,  easily  torn,  and  bathed 
with  a  thin,  sanious  fluid,  of  an  excessively  fetid  odor.  In  some 
instances,  the  eschars  are  of  a  greenish,  graj'ish,  or  drab  color, 
and  have  a  sort  of  depressed  appearance,  as  if  they  were  sunk 
beneath  the  natural  level.  The  parts  immediately  around  the 
seat  of  the  gangrene  are  generally  remarkably  tumid  and  spongy, 
from  the  distention  of  the  capillary  vessels  and  the  presence  of 
effused  fluids.  The  submucous  connective  substance  at  the 
aftected  part,  as  well  as  for  some  distance  beyond,  is  infiltrated 
3 


34  INFLAMMATION    OF    THE    BLADDER. 

with  bloody  matter,  and  yields  under  the  slightest  pressure;  the 
muscular  fibres  are  preternatu rally  dark  and  lacerable;  and  the 
peritoneal  investment  exhibits  all  the  evidences  of  high  inflam- 
matory action,  being  more  or  less  discolored,  incrusted  with 
lymph,  and  adherent  to  the  neighboring  parts.  In  cases  where 
the  disease  does  not  speedily  terminate  life,  the  muscular  coat 
is  sometimes  denuded  over  a  large  space,  and  the  sloughs  lie 
loose  in  the  urinary  reservoir,  small  fragments  of  them  having 
perhaps  been  voided  during  life. 

Gangrene  of  the  bladder  is  sometimes  followed  by  rupture 
of  the  coats  of  this  organ,  and  the  escape  of  its  contents.  This 
event  is  most  likely  to  happen  when  there  has  been  protracted 
retention  of  urine  with  inordinate  distention,  and  may  take  place 
very  suddenly,  while  the  patient,  perhaps,  is  turning  about  in 
bed,  or  during  a  fit  of  coughing  or  vomiting ;  or  it  may  occur 
slowly  and  gradually,  as  a  result  of  ulceration.  In  the  latter 
case,  the  opening  is  generally  small,  and  is  often  accompanied 
by  an  eftusion  of  lymph  upon  the  outer  surface  of  the  organ,  or, 
what  is  the  same  thing,  by  an  imperfect  agglutination  of  the 
bladder  to  the  neighboring  parts.  When  the  rupture  occurs 
spontaneously,  or  under  the  influence  of  muscular  exertion,  it 
is  always  followed  by  an  esca})e  of  urine,  either  into  the  cavity 
of  the  abdomen,  or  into  the  connective  tissue  of  the  pelvis.  In 
either  case,  the  ultimate  consequences  are  the  same.  Violent 
peritonitis  soon  arises,  attended  by  the  most  intense  suffering, 
and  terminating  fatally  in  a  very  few  days.  The  patient  is  in- 
stantly seized  with  the  most  agonizing  pain,  with  an  inability 
to  move  or  turn  about,  and  a  sense  of  profound  depression ; 
symptoms  which  are  always  sufficiently  characteristic  of  the  true 
nature  of  the  accident. 

The  prognosis  of  this  disease  is  always  unfavorable.  Recovery, 
it  is  true,  sometimes  occurs  even  when  the  gangrene  is  appa- 
rently ex:tensive,  but  such  an  event  must  always  be  regarded  as 
an  exceptional  one.  In  general,  the  inflammation  which  pre- 
cedes and  accompanies  the  mortification,  even  when  the  latter 
is  slight,  is  so  severe,  and  causes  such  an  amount  of  local  and 
constitutional  suttering,  that  few  systems,  however  strong  and 
robust,  can  withstand  its  deleterious  effects.  Aware  of  these 
facts,  the  practitioner  cannot  be  too  cautious  in  delivering  his 
opinion  as  to  the  probable  issue  of  any  particular  case. 


ULCERATION  OF  THE  BLADDER.  .  35 

The  treatment  of  gangrene  of  the  bladder  is  easily  told.  The 
object  is  to  prevent  the  lesion  rather  than  to  cure  it  after  it  has 
been  established.  With  this  view,  the  practitioner  must  re- 
double his  etlbrts  the  moment  he  sees  that  this  event  is  threat- 
ened, and  endeavor,  by  a  judicious  and  well-directed  course  of 
treatment,  to  arrest  the  inflammatory  action.  Should  gangrene 
be  inevitable,  the  indication  is  to  support  the  system,  and  by 
means  of  quinine,  ammonia,  brand}',  opiates,  and  nutritious  food, 
assist  the  patient  in  throwing  otf  the  efi'ects  of  the  local  disorder. 
The  distention  of  the  bladder  is  obviated  by  the  catheter. 
Should  rupture  take  place,  with  infiltration  of  urine  into  the 
connective  tissue  of  the  pelvis,  the  perineum  should  be  freely 
opened. 

Sect.  V.— ULCERATION  OF  THE  BLADDER. 

Judging  from  the  results  of  my  own  observations,  both  at  the 
bedside  and  in  the  dissecting-room,  I  am  disposed  to  rank  ulcer- 
ation among  the  rarest  terminations  of  acute  cystitis.  The  ulcers, 
which  are  most  common  in  the  neck  and  bas-fond,  are  usually 
neither  numerous  nor  large.  In  fact,  it  is  rare,  in  any  case,  to 
find  more  than  two  or  three,  and  these  may  be  so  small  as  to 
elude  superficial  inspection,  particularly  when  the  morbid  pro- 
cess is  confined  to  the  mucous  follicles.  Sometimes,  however,  the 
number  is  much  greater,  and  the  size  more  considerable,  the 
lining  membrane  exhibiting,  in  consequence,  a  ragged,  riddled 
appearance.  At  other  times  again,  but  very  infrequently,  there 
is  a  single  ulcer,  so  large  as  to  occupy  the  greater  portion  of  the 
organ,  and  denude  the  muscular  fibres  as  thoroughly  as  if  they 
had  been  dissected  with  the  knife.  Their  most  common  appear- 
ance is  that  of  cleanly  punched  holes,  resting  upon  the  submucous 
coimective  tissue,  of  circular  or  oval  form,  with  slightly  elevated 
edges.  Not  uncommonly  they  are  exceedingly  irregular  in  their 
outline,  and  their  edges  are  hard  and  thick,  fissured,  puckered, 
or  jagged.  These  peculiarities  are  most  common  in  old,  chronic 
cases.  As  the  disease  progresses,  the  erosion  may  extend  through 
the  submucous  tissue  to  the  muscular  walls,  which,  in  their  turn, 
may  be  penetrated,  and  the  serous  covering  be  invaded,  eventu- 
ating in  perforation,  followed  by  the  escape  of  urine,  and  the 
development  of  fatal  peritonitis  ;  or  by  adhesion  of  the  organ  to 


36  INFLAMMATION    OF    THE    BLADDER. 

the  sigmoid  flexure  of  tlie  colon,  or  one  of  the  coils  of  the  small 
intestine,  which  may  be  destroyed  layer  by  layer,  until  a  com- 
munication is  established,  through  which  there  is  a  reciprocal 
passage  of  their  contents.  In  the  female,  the  ulcer  sometimes 
opens  into  the  uterus  or  the  vagina;  and,  in  both  sexes,  not 
infrequently  into  the  rectum. 

The  most  frequent  cause  of  ulceration  of  the  bladder  is  pro- 
tracted chronic  cystitis,  arising  from  stricture  of  the  urethra  and 
enlargement  of  the  prostate,  although  acute  inflammation  may 
terminate  in  this  way.  Paralysis  of  the  bladder,  injury  of  the 
spinal  cord,  and  organic  lesions  of  the  kidneys,  are  very  apt  to 
induce  it,  from  the  changes  which  they  eftect  in  the  composition 
of  the  urine.  The  presence  of  a  calculus,  or  of  the  beak  of  a 
catheter  permanently  retained  in  the  bladder,  for  drawing  off 
the  urine,  as  in  paralysis  of  this  organ,  often  occasions  ulceration 
by  the  pressure  which  they  exert  upon  the  mucous  membrane. 
It  would  appear,  from  the  cases  of  it  upon  record,  that  the  dis- 
ease is  more  frequent  in  women  than  in  men,  and  in  old,  decrepit, 
than  in  young,  vigorous  subjects. 

The  symptoms  of  ulcerated  bladder  do  not  differ  essentially, 
in  the  early  stage  of  the  disease,  from  those  of  subacute  or  chro- 
nic inflammation.  Even  at  a  later  period,  they  are  not  always 
distinct,  or  well  marked.  The  most  prominent  local  phenomena 
are,  pain  and  uneasiness  in  the  pelvic  cavity,  with  spasm,  frequent 
micturition,  and  an  oftensive  state  of  the  urine.  The  pain  is  of 
an  acute,  burning,  or  scalding  character,  and  is  aggravated  by 
exercise,  an  overloaded  state  of  the  bowels,  by  pressure  on  the 
hypogastric  region,  the  perineum,  and  the  anus,  by  the  finger  in 
the  rectum  or  vagina,  and  by  the  introduction  of  the  catheter. 
It  often  darts  along  the  course  of  the  ureters  to  the  loins,  and  is 
always  most  severe  during  the  passage  of  the  urine  and  for  a  few 
minutes  after,  when  it  disappears,  but  returns  again  as  the  secre- 
tion accumulates.  In  many  cases,  there  is  severe  pain  in  the  loins 
and  kidneys,  and  in  the  groins  and  the  upper  part  of  the  thighs. 
In  the  female,  there  is  often  a  burning  sensation  at  the  orifice  of 
the  urethra ;  and  in  the  male,  the  testicles  are  sometimes  ex- 
quisitely tender,  and  there  is  great  distress,  with  more  or  less 
itching,  in  the  prepuce  and  the  head  of  the  penis. 

The  inclination  to  urinate  is  not  incessant,  but  comes  on  in 
paroxysms,  which    gradually  increase    in    frequency,  and   are 


ULCERATION  OF  THE  BLADDER.  37 

attended  with  intense  suffering.  The  urine  is  expelled  with 
much  difficulty,  or  voided  in  droj^s,  accompanied  with  an  almost 
insupportable  scalding  of  the  urethra.  Gradually,  perhaps 
suddenly,  the  pain  and  distress  subside,  and  the  patient,  exhausted 
by  his  exertions,  sinks  into  a  somnolent  state,  from  which  he  is 
roused  in  fifteen  or  tAventy  minutes  to  pass  through  a  similar 
ordeal. 

The  urine  is  generally  acid  and  slightly  albuminous,  and  de- 
posits, on  cooling,  a  considerable  amount  of  thick,  ropy  mucus: 
sometimes  it  contains  fine  shreds  of  lymph,  or  the  debris  of  the 
affected  membrane.  In  tbe  advanced  stages  of  the  complaint,  it 
is  excessively  offensive,  of  a  dark  color,  occasionally  like  coftee- 
grounds  in  appearance,  and  often  mixed  with  pus,  or  tinged  with 
blood.  An  ammoniacal  state  of  this  fluid  is  not  uncommon  at 
this  period.  Where  there  is  extensive  destruction  of  the  lining 
membrane,  little  or  no  mucus  is  seen  in  the  urine. 

As  the  disease  progresses,  the  sympathies  and  functions  of  the 
urinary  organs  are  completely  subverted,  and  the  patient's  health 
is  materially  impaired  by  the  local  derangement.  In  protracted 
cases,  or  where  the  destruction  of  the  mucous  membrane  is  exten- 
sive, pains  are  felt  in  the  perineum  and  the  rectum,  only  a  few 
drops  of  urine  can  be  retained  at  a  time,  the  body  is  excessively 
emaciated,  and  the  patient  dies  gradually  exhausted  by  his  sufter- 
ing.  Sometimes,  however,  on  the  other  hand,  the  symptoms  are 
comparatively  mild,  and  but  little  distress  is  experienced  in  the 
urinary  apparatus,  from  the  commencement  to  the  termination 
of  the  case. 

The  diagnosis  of  this  malady  is  difficult,  and  cannot  always 
be  determined  during  life.  The  aft'ections  for  which  it  is  most 
liable  to  be  mistaken  are  simple  cystitis,  catarrh,  and  stone. 
From  the  former  it  can  generally  be  distinguished  by  its  ob- 
stinate persistence,  by  the  greater  extent  and  violence  of  the 
local  distress,  by  the  incessant  desire  to  void  the  urine,  which  is 
never  suft'ered  to  accumulate,  by  the  more  frequent  recurrence 
of  spasms,  by  the  more  severe  burning  or  scalding  along  the 
urethra,  and,  lastlj^^,  b}^  the  presence  of  pus  in  the  urine,  and,  in 
the  more  aggravated  forms  of  the  complaint,  by  the  absence  of 
nmcus.  In  catarrh,  the  characteristic  symptom  is  a  copious 
secretion  of  thick,  tough,  ropy  mucus,  with  a  turbid  appearance 
and  an  ammoniacal  odor  of  the  urine.     The  local  and  constitu- 


38  INFLAMMATION    OF    THE    BLADDER. 

tional  distress  is  less  severe  than  in  ulceration,  the  desire  to 
micturate  is  not  so  frequent,  there  is  less  sensibility  in  the 
uretlira,  and  there  is  often  complete  intermission  of  the  vesical 
disturbance,  tlie  patient  remaining  comparatively  comfortable 
for  days  and  weeks.  In  ulceration,  the  symptoms  are  persistent, 
and  the  disease  steadily  proceeds  from  bad  to  worse.  In  stone, 
the  pain  is  most  severe  immediately  after  micturition,  and  is 
generally  much  aggravated  by  rough  exercise,  the  urine  is  also 
more  frequently  bloody,  there  is  less  irritability  of  the  urethra, 
and  the  intervals  between  the  paroxysms  are  longer  than  in 
ulceration.  If  doubt  exist,  the  sound  is  used,  cautiously  and 
gently,  lest,  if  the  case  be  one  of  ulceration,  it  increase  the  local 
inflammation,  and  endanger  life.  In  ulceration  there  is  some- 
times a  discharge  of  the  d6bris  of  the  mucous  membrane,  which 
never  happens  in  simple  cystitis,  catarrh,  and  calculous  disorder. 
It  should  be  carefully  distinguished  from  the  shreds  of  lymph 
which  are  occasionally  voided  in  croupous  inflammation. 

When  perforations  exist,  a  discharge  of  gas,  fecal  matter, 
ingcsta,  and  other  substances,  along  with  the  urine,  leaves  no 
doubt  respecting  the  nature  of  the  disease.  The  gas  occasionally 
passes  by  the  urethra  with  an  explosive  noise,  or  in  little  bub- 
bles mixed  with  urine.  An  escape  of  urine  by  tlie  anus  or 
vulva  indicates  that  the  ulcer  has  taken  the  direction  of  the 
rectum  or  vagina. 

The  prognosis  of  this  disease  is  most  unfavorable.  That 
cures  are  occasionally  effected,  and  that  too  without  the  aid  of 
much  treatment,  is  unquestionably  true ;  but  such  a  result  must 
be  regarded  as  extremely  rare.  Generally  sj)eakiug,  the  ulcera- 
tive i»rocess  proceeds  in  spite  of  the  best  directed  ettbrts  of  the 
practitioner,  gradually  undermining  the  health,  and  exhausting 
the  vital  powers.  The  period  at  which  death  occurs  varies  from 
five  or  six  months  to  several  3^ears. 

In  ulceration  of  the  bladder  there  is  nearly  always  more  or 
less  disease  of  the  urethra,  prostate  gland,  seminal  vesicles,  the 
ureters,  and  kidneys.  All  these  organs  are  not  necessarily  in- 
volved at  the  same  time,  but  not  infrequently  this  is  the  case, 
and  there  are  few  instances  in  which  several  of  them  do  not 
participate  in  the  vesical  aflfection.  The  most  common  lesion 
of  the  urethra  is  inflammation  of  its  lining  membrane,  which  is 
usually  most  conspicuous  near  the  neck  of  the  bladder,  and  is 


ULCERATIOX  OF  THE  BLADDEE.  39 

sometimes  marked  by  high  vascularity.  The  prostate  gland  is 
usually  enlarged,  softened  in  its  texture,  and  engorged  with 
blood  ;  occasionally  its  ducts  are  expanded,  and  its  substance  is 
pervaded  by  pus  or  sanious  iiuid.  It  is  rare  that  this  body  suf- 
fers from  an  encroachment  of  the  ulceration.  The  seminal  vesi- 
cles seldom  entirely  escape  the  ravages  of  the  malady.  The  most 
frequent  morbid  appearance  of  these  reservoirs  is  high  discolora- 
tion of  their  lining  membrane,  with  softening  of  their  texture, 
and  an  infiltrated  and  injected  condition  of  the  connective  tissue 
by  which  they  are  connected  to  the  bladder.  Their  contents 
usually  exhibit  the  character  of  spoiled  semen,  which  is  some- 
times of  a  very  fetid  odor.  The  ureters  are  variously  affected  ; 
inflamed,  ulcerated,  dilated,  contracted,  thickened,  or  attenu- 
ated. One  of  the  kidneys  is  sometimes  natural,  but,  in  general, 
both  are  implicated,  though  not  in  an  equal  degree.  The  lesion 
most  commonly  met  with  in  these  organs  is  inflammation,  with 
ulceration  of  their'  substance,  and  a  pretty  copious  secretion  of 
pus.  Another  not  infrequent  effect  is  atrophy,  and  cases  occur 
in  which  one  of  these  glands  is  converted  into  a  membranous 
pouch,  totally  devoid  of  parenchymatous  tissue,  and  filled  with 
sero-purulent  fluid. 

The  bladder,  in  this  disease,  presents  no  uniformity  in  regard 
to  its  pathological  appearances.  Its  capacity  is  normal,  dimin- 
ished, or  increased  ;  the  muscular  fibres  are  preternaturally  dis- 
tinct, and  of  a  deep  red  color ;  the  mucous  membrane,  when  not 
completely  destroyed,  is  sometimes  covered  with  patches  of 
lymph,  and  is  nearly  always  remarkably  thick,  spongy,  and  vas- 
cular, immediately  round  the  ulcers.  Purulent  matter,  mixed 
with  shreds  of  fibrin  and  the  debris  of  the  lining  membrane,  is 
generally  found  in  the  bottom  of  the  bladder,  and  is  derived 
either  from  this  organ  itself  or  from  the  ureters  and  the  kid- 
neys. The  peritoneal  investment,  although  usually  healthy,  is 
sometimes  partially  covered  with  lymph,  and  pretty  firmly  ad- 
herent to  the  neighboring  parts.  Occasionally  the  coats  of  the 
viscus  are  exceedingly  soft,  and  incapable  of  resisting  the  slight- 
est traction.  In  other  cases,  again,  they  are  remarkably  tough 
and  indurated,  owing,  doubtless,  to  interstitial  plastic  deposits. 

If  perforations  and  adhesions  form,  in  consequence  of  this  dis- 
ease, it  is  remarkable  how  long  the  patient  may  live  with  this 
loathsome  infirmity.     I  am  acquainted  with  a  clergj-man,  now 


40  INFLAMMATION    OF    THE    BLADDER. 

eighty-five  years  old,  from  whose  bhidder  fecal  matter  has  been 
discharged  for  upwards  of  a  quarter  of  a  century.  His  health, 
with  the  exception  of  an  occasional  attack  of  colic,  has  been  ex- 
cellent. The  passage  of  feces  along  this  route  occurred,  at  first, 
at  long  intervals,  and  rarely  continued  longer  than  three  or  four 
days  at  a  time ;  of  late,  it  has  been  much  more  frequent,  and 
within  the  last  twelve  months,  almost  constant.  When  perfora- 
tion takes  place  without  adhes-ion,  death  generally  supervenes, 
in  from  twenty-four  to  forty-eight  hours,  from  inflammation  of 
the  peritoneum. 

When  the  opening  into  the  boAvel  is  so  large  as  to  allow  most 
of  the  urine  to  escape  l)y  that  route,  the  patient  will  usually  be 
affected  with  diarrhoea,  excited  by  the  contact  of  the  irritat- 
ing fluid.  In  tliis  way,  the  intestinal  disorder  may  he  main- 
tained for  many  months,  perhaps,  indeed,  for  years,  without  any 
suspicion  on  the  part  of  the  patient,  and  his  physician,  of  its 
real  nature. 

From  what  has  been  said  under  the  head  of  cystitis,  the  prac- 
titioner will  have  no  difficulty  in  deducing  the  principles  which 
ought  to  guide  him  in  the  management  of  ulceration  of  the 
bladder.  At  the  commencement  of  the  complaint,  the  means 
employed  to  arrest  it  must  be  strictly  antiphlogistic,  while  sub- 
sequently they  must  be  modified  to  meet  individual  contingen- 
cies, as  they  are  developed  under  the  eye  of  .the  practitioner. 
Active  depletion  by  the  lancet  will  seldom  be  called  for  after 
the  ex[»iration  of  the  first  week  or  ten  days :  while  the  local 
abstraction  of  blood  by  leeches  is  proper  in  every  stage  of  the 
disorder,  and  constitutes  one  of  our  most  valuable  therapeutic 
resources.  The  best  regions  for  applying  them  are  the  perineum, 
the  parts  around  the  anus,  the  upper  and  inner  surface  of  the 
thighs,  and  the  inferior  portion  of  the  abdomen,  the  number 
being  proportioned  to  the  exigencies  of  each  particular  case. 

The  bowels  should  be  constantly  kei»t  in  a  soluble  condition 
by  mild  ajierients,  the  diet  should  be  light,  but  nutritious,  and 
the  drinks,  which  should  be  taken  in  great  moderation,  so  as 
not  to  increase  unduly  the  renal  secretion,  should  consist  of  plain 
water,  linseed  tea,  or  gum  Arabic  water.  The  patient  should 
constantly  wear  fiannel  next  the  skin,  and  carefully  guard 
against  sudden  vicissitudes  of  temperature.  He  should,  more- 
over, keep  himself  as  much  as  possible  in  the  recumbent  posture. 


ULCERATION  OF  THE  BLADDER.  41 

Sexual  intercourse,  and  rough  exercise  of  every  description,  must 
be  carefully  avoided. 

Of  the  internal  remedies  calculated  to  act  directly  upon  the 
urinary  apparatus,  the  most  important  are  buchu,  uva  ursi,  and 
hops,  which  may  be  administered  either  in  the  form  of  infusion, 
decoction,  or  extract,  alone,  or  variously  combined  with  each 
other,  or  with  copaiba,  cubebs,  hyoscyamus,  cicuta,  the  alkalies, 
the  mineral  acids,  or  tincture  of  the  chloride  of  iron.  These 
articles  are  all  beneficial  in  ulceration  of  the  bladder,  but  expe- 
rience has  shown  that  none  of  them  retain  their  good  effects 
beyond  a  few  days.  It  is  important,  therefore,  that  they  should 
be  frequently  changed  or  varied,  and  not  be  continued  too  long 
at  a  time. 

Whatever  mode  of  treatment  be  employed,  opium,  laudanum, 
or  morphia  is  indispensable  for  quieting  the  bladder  and  pro- 
curing sleep.  The  most  eligible,  or  least  objectionable  form  of 
administration  is  that  of  an  enema,  or  a  suppository  ;  but  it  may 
also  be  given  hypodermically,  or  by  the  mouth,  although,  in  the 
latter  way,  it  is  more  apt  to  produce  constipation  and  derange- 
ment of  the  digestive  function.  In  whatever  manner  it  be  exhi- 
bited, it  should  be  employed  in  full  doses,  repeated  at  longer  or 
shorter  intervals,  according  to  the  exigencies  of  each  individual 
case.  Small  doses,  frequently  repeated,  only  serve  to  render  the 
system  irritable  without  relieving  the  local  suft'ering. 

Local  remedies,  or  means  addressed  directly  to  the  aftected 
surface,  are  sometimes  highly  serviceable,  the  best  being  such  as 
are  of  an  anodyne  character,  as  infusion  of  poppy,  opium,  hops, 
aconite,  and  cicuta  ;  the  salts  of  morphia  have  also  been  recom- 
mended ;  and  benefit  has  sometimes  followed  the  use  of  warm 
water,  either  simple,  or  medicated  with  tar,  tannic  acid,  sulphate 
of  zinc,  creasote,  nitrate  of  silver,  and  other  substances.  Lime- 
water,  black-w^ash,  and  a  weak  solution  of  iodine  have  occasion- 
ally proved  advantageous.  The  amount  of  reliance  to  be  placed 
upon  these  remedies  may  be  readily  inferred  from  their  number 
and  variety.  Like  the  internal  means,  above  alluded  to,  they 
soon  lose  their  beneficial  efiects,  and  are  sometimes  positively 
injurious.  Great  caution,  in  fact,  is  always  necessary  in  their 
employment.  The  best  mode  of  introducing  them  is  by  means 
of  a  gum-elastic  bag,  carefully  adapted  to  the  end  of  a  soft 
catheter.     The  quantity  of  any  injection  of  this  kind  should 


42  INFLAMMATION    OF    THE    BLADDER. 

not,  at  first,  exceed  an  ounce,  or  an  ounce  and  a  half;  afterwards 
it  may  be  gradually  increased  to  three  or  even  four  ounces.  An 
anodyne  injection  should  be  retained  as  long  as  possible;  an 
astringent  one,  not  more  than  a  few  minutes. 

In  females,  in  whom  this  affection  is  most  common,  the  ulce- 
rated surface  may  readily  be  brought  into  view,  by  means  of 
Simon's  speculum,  shown  in  fig.  32,  when  it  may  be  touched 
with  nitrate  of  silver,  dilute  acid  nitrate  of  mercury-,  an  alcoholic 
solution  of  corrosive  sublimate,  carbolic  acid,  or  sulphuret  of 
carbon.  "When  the  disease  proves  obstinate,  it  is  due  to  the 
constant  and  painful  spasmodic  contractions  of  the  bladder,  so 
that  the  best  chance  of  relief  is  held  out  by  placing  the  viscus 
at  rest  by  an  incision,  which,  commencing  at  the  posterior 
fourth  of  the  urethra,  is  carried  through  the  median  line  of  the 
vesico-vaginal  septum,  and  terminates  on  a  level  with  the  ori- 
fices of  the  ureters.  In  this  way,  the  late  Sir  James  Y.  Simpson 
cured  two  patients  ;  and  Bozeman,  Emmet,  Sims,  Parvin,  Simon, 
Hegar,  and  other  surgeons,  have  been  equally  successful.  In  place 
of  resorting  to  colpocystotomy.  Dr.  Hunter  McGruire,^  of  Rich- 
mond, secured  a  free  and  constant  escape  of  the  urine,  in  a  case  of 
this  nature  of  eight  j'ears'  duration,  by  introducing  a  drainage 
tube  into  the  bladder,  where  it  was  retained  b}'  bands  passed  around 
the  hips.  At  the  expiration  of  six  weeks,  the  free  end  of  the 
tube  was  attached  to  a  gum  bag,  which  was  fastened  to  the 
thigh,  and  the  patient  was  allowed  to  leave  her  bed  and  walk 
about.  This  course  Avas  persisted  in  for  four  months.  For 
some  days  after  the  removal  of  the  tube,  there  was  incon- 
tinence, but  the  bladder  soon  regained  its  power ;  and  eight 
months  from  the  commencement  of  the  treatment,  the  woman 
could  retain  her  urine  for  three  hours,  and  pass  it  without  pain. 

'  Virginia  Medical  Monthly,  1874. 


CHAPTER    II. 

CHRONIC  INFLAMMATION  OF  THE  BLADDER,  AND  ITS 
RESULTS. 

Sect.  L— CATARRH  OF  THE  BLADDER. 

Catarrh  of  the  bladder,  technically  denominated  cystorrhcea, 
signifies  an  inordinate  secretion  of  white,  glairy  muco-pnrulent 
fluid,  dependent  upon  clironic  inflammation  of  the  lining  mem- 
brane. It  is  analogous  in  its  character  to  gleet,  leucorrhoca,  and 
other  kindred  affections,  and  is  generally  a  symptom  merely  of 
a  more  serious  disease.  Of  the  various  names  that  have  been 
employed  to  designate  it,  the  most  appropriate  and  expressive 
is  cystorrhoea. 

This  disease  has  usually  been  described  by  authors  as  consist- 
ing of  two  varieties,  the  acute  and  tlie  chronic  ;  an  arrangement 
for  which,  I  conceive,  there  is  no  necessity,  since  the  former 
affection  does  not  differ  in  any  respect  from  suppurative  cystitis, 
described  in  the  preceding  chapter.  This  distinction  is  of  prac- 
tical importance,  and  should  not  be  lost  sight  of  in  the  further 
consideration  of  the  subject. 

Catarrh  of  the  bladder  is  almost  peculiar  to  advanced  age.  I 
have  never  met  with  it  before  puberty,  except  as  an  attendant 
upon  stone,  and  but  very  rarely,  under  any  circumstances,  before 
the  forty-fifth  or  fiftieth  year.  Persons  of  a  gouty  or  rheumatic 
habit  are  supposed  to  be  particularly  obnoxious  to  it ;  but  of 
this  I  have  witnessed  no  corroborative  facts  in  my  own  practice. 
The  disease  is  also  said  to  be  more  common  in  winter  than  in 
summer,  and  in  cold  than  in  warm  climates ;  and  it  is  asserted 
that  it  may  prevail  epidemically.  Finally,  males  are  more  liable 
to  it  than  females,  for  the  obvious  reason  that  they  are  more 
subject  to  obstruction  of  the  urinary  passages,  and  to  all  kinds 
of  exposure. 

Cystorrhoea  is  always  dependent,  directly  or  indirectly,  upon 
some  obstacle  to  the  evacuation  of  the  urine,  or  upon  a  diseased 
condition   of  the   bladder   itself.      Hence,   the   most   common 


44  CHROXIC    INFLAMMATION    OF    THE    BLADDER. 

exciting  causes  are  stricture  of  the  urethra,  the  presence  of  a 
vesical  calculus,  and  enlargement  of  the  prostate  gland.  In  the 
female,  it  is  not  uncommon  from  partial  retention  of  urine, 
induced  bj  compression  of  the  urethra  against  the  pubic  sym- 
physis, or  changes  in  the  position  of  the  urethra,  in  consequence 
of  malpositions  of  the  utemis,  or  conditions  external  to  that 
organ,  pressing  upon  or  dragging  down  the  bladder.  Paralysis 
of  the  bladder,  whether  produced  by  overdistention  of  the  organ 
by  urine,  or  injury  or  disease  of  the  spine,  frequently  gives  rise 
to  this  state ;  and  it  is  a  constant  attendant  upon  sacculation, 
ulceration,  hypertrophy,  and  carcinoma  of  the  bladder.  In  all 
these  affections  the  bladder  is  never  entirely  emptied  either 
voluntarily  or  by  the  catheter,  but  a  portion  of  the  urine 
remains  behind,  and  is  speedily  decomposed,  with  the  evolution 
of  carbonate  of  ammonia,  which,  acting  as  a  chemical  irritant,  is 
a  powerful  factor  in  the  production  of  the  disease.  When  it  is 
once  established,  it  is  easily  aggravated  or  reinduced  by  exposure 
to  cold,  exercise  on  horseback,  sounding,  venereal  excesses, 
drastic  purgatives,  indulgence  in  ardent  sj^irits,  stimulating 
food,  irritating  injections,  diuretics,  and  other  remedies,  as 
turpentine  and  cantharides,  overdistention  of  the  bladder, 
neuralgia,  retrocession  of  gout,  repulsion  of  cutaneous  erup- 
tions, local  injury  and  disease  of  the  adjoining  parts,  as  the 
anus,  rectum,  vagina,  and  uterus. 

Cystorrhcea  generally  comes  on  in  a  slow,  gradual,  and  insidi- 
ous manner ;  and  hence  there  is  frequently  serious  structural 
lesion  before  the  true  character  of  the  malady  is  revealed,  or 
even  suspected.  The  obstruction  to  the  evacuation  of  the  urine 
upon  which  it  commonly  depends,  absorbs  for  a  time  the 
patient's  entire  attention,  and  it  is  only  by  accident  that  he  is  at 
length  apprised  of  the  real  condition  of  the  bladder.  The 
inflammation  which  accompanies  the  affection,  and  wdiich  is 
always  the  immediate  cause  of  the  cystorrhcea,  is  of  a  chronic 
character,  and  usually,  in  the  first  instance,  of  a  very  mild  grade. 
It  is  for  this  reason  that  the  term  subacute  has  been  sometimes 
applied  to  it. 

The  gharacteristic  symptoms  of  the  disease  are  hypersecretion 
of  mucus  and  pus,  an  altered  condition  of  the  urine,  frequent 
and  difficult  micturition,  pain  in  the  region  of  the  affected 
organ,  as  well  as  in  the  adjoining  parts,  and  more  or  less  consti- 


CATAERH  OF  THE  BLADDER.  45 

tutional  derangement.  In  the  incipient  stages,  and  in  the 
milder  forms  of  the  affection,  the  quantity  of  mucus  secreted  is 
generally  small,  not  exceeding  perhaps  a  few  drachms  in  the 
twenty-four  hours.  At  a  more  advanced  period,  the  quantity  is 
often  considerable;  and  in  some  instances  the  discharge  is  truly 
enormous,  as  in  the  case  of  a  patient,  mentioned  by  Barthoz, 
who  voided  not  less  than  fifteen  pounds  in  thirty-six  hours. 
This,  however,  is  a  rare  exception.  Very  frequently  the  mucus 
amounts  to  one-third,  and  even  one-half  of  the  entire  discharge. 
In  the  early  period  of  the  disease,  it  is  so  intimately  blended 
with  the  urine  that  it  does  not  become  perceptible  until  the 
latter  begins  to  cool.  It  then  presents  itself  in  the  form  of  an 
opaque,  grayish,  or  whitish  cloud,  fleecy 
in  its  appearance,  and  at  first  suspended  ^S-  ■^• 

in  the  fluid,  but  gradually  subsiding  to 
the  bottom.  Its  consistence  gradually 
augments  as  the  urine  cools.  Not  unfre- 
quentl}^  it  occurs  in  flakes,  strings,  or 
small  lumps.  In  the  confirmed  stage  of  the 
affection,  it  is  always  thick,  ropy,  tena- 
cious, and  semitransparent,  and  separates 
from  the  urine  durino;  micturition,  or  im-    „  .       ^ 

"-'  _  '  Urinary  Deposits  in  Cystonlioea. 

mediately  after.     It  always  in  such  cases 

adheres  with  great  firmness  to  the  bottom  of  the  receiver,  and 

is  often  so  glutinous  that  in  pouring  it  from  one  vessel  into 

another  it  draws  itself  out  upwards  of  a  foot  in  length  without 

breaking. 

The  urine,  in  the  early  stage  of  the  complaint,  is  nearly 
natural,  both  in  its  color,  odor,  consistence,  and  chemical  pro- 
perties. By  degrees,  however,  it  assumes  a  turbid,  muddy  aspect, 
becomes  more  or  less  offensive,  and  is  thick,  acrid,  alkaline,  and 
surcharged  with  triple  phosphates,  pus,  and  epithelium,  as  shown 
in  fig.  1,  from  a  drawing  by  Dr.  Brewster,  one  of  my  former 
clinical  assistants.  During  the  progress  of  the  disease,  it  always 
becomes  highly  acrid,  so  that  the  bladder  can  hardly  tolerate  it 
even  for  a  few  minutes.  It  generally  emits  a  peculiar  ammo- 
niacal  odor,  is  rapidly  decomposed,  both  in  the  bladder  and  out 
of  it,  and  is  mixed  with  epithelium,  urate  of  ammonia,  purulent 
and  phosphatic  matter,  and  bacteria.  If  a  silver  catheter  is 
used  at  this  stage,  it  usually  comes  out  of  the  bladder  of  a 


46  CHRONIC    INFLAMMATION    OF    THE    BLADDER. 

bronze,  brownish,  or  black  color,  in  consequence  of  the  presence 
of  a  minute  quantity  of  sulphuretted  hydrogen. 

The  pus  wiiich  is  present  in  this  disease  is  derived  from 
various  sources ;  sometimes  from  the  bladder,  sometimes  from 
the  ureters,  or  the  prostate  gland,  but  in  general  from  the 
kidneys,  one  or  both  of  which  are  t)ften  seriously  involved  in 
the  mischief.  Its  presence  is  always  to  be  regarded  with  great 
attention,  as  it  is  generally  indicative  of  serious  disease  of  the 
organs  from  which  it  is  derived.  It  should  be  remembered  that 
the  glairy,  tenacious  deposit  in  this  affection  is  in  reality  not 
simple  mucus,  although  it  resembles  it.  Through  the  decompo- 
sition of  the  urea  of  the  stagnant  urine,  carbonate  of  ammonia 
is  generated,  which  not  only  occasions  the  alkalescence  and 
acridness  of  the  liuid,  but  effects  a  change  in  the  associated  dis- 
charge of  [)us,  to  which  the  peculiar  characteristics  of  the  deposit 
are  largly  due. 

The  urine  is  voided  frequently,  in  small  quantity,  and  with 
more  or  less  difficulty.  Generally,  it  passes  off  in  interrupted 
jets,  in  a  small,  feeble  stream,  or  in  drops,  accompanied  by  violent 
spasm  and  straining.  Great  effort  is  often  required  to  start  it, 
and  it  rarely  happens  that  the  whole  of  it  is  evacuated  at  any 
one  time.  When  tlie  urine  is  loaded  with  thick,  ropy  deposit, 
the  difficulty  of  voiding  it  is  much  increased,  and  the  patient  is 
frequently  obliged  to  have  recourse  to  the  catheter. 

The  pain  attending  this  affection  is  liable  to  much  diversity. 
In  general,  it  is  of  an  obtuse,  or  a  dull,  heavy,  aching  character, 
and  is  situated  above  the  pubes.  In  the  more  aggravated  forms 
of  the  disease,  it  is  scalding,  burning,  pricking  or  spasmodic,  and 
accompanied  with  the  most  violent  straining  and  tenesmus.  It 
is  usually  most  severe  at  the  commencement  of  micturition,  and 
gradually  reappears  as  the  bladder  refills.  It  is  liable  to  be 
aggravated  by  exposure  to  cold,  venereal  indulgence,  rough 
exercise,  the  erect  posture,  pressure  on  the  abdomen,  drastic 
purgatives,  and  whatever  has  a  tendency  to  augment  the  secre- 
tion of  mucus. 

Patients  ati'ected  with  cystorrhoea  are  sometimes  impotent, 
even  if  they  are  comparatively  young.  I  have  met  with  several 
instances  of  this  kind.  In  one  remarkable  case,  the  gentleman, 
forty-four  years  of  age,  had  experienced  no  sexual  desire  for 
upwards  of  six  years,  though  he  was  naturally  of  an  amorous 


CATAERH  OF  THE  BLADDEE.  47 

disposition.  His  penis  had  become  soft  and  flabby,  and  had  not 
been  in  a  state  of  complete  erection  for  a  long  time.  He  had 
occasional  emissions,  but  they  were  always  unaccompanied  with 
the  proper  feeling.  Owing  to  the  frequent  micturition  which 
forms  so  striking  a  feature  of  tliis  disease,  and  the  severe  strain- 
ing which  generally  attends  it,  catarrh  of  the  bladder  is  often 
complicated  with  hemorrhoids,  prolapse  of  the  bowel,  swelling 
of  the  testes,  and  even  with  hernia. 

Tlie  prognosis  in  cystorrhoea  varies  with  many  circumstances 
which  hardly  admit  of  precise  detail.  Much  will  necessarily 
depend  upon  the  age  and  constitution  of  the  patient,  the  duration 
of  the  disease,  and  the  condition  of  the  bladder  and  of  the  asso- 
ciated organs.  In  its  incipient  stage,  it  is  sometimes  not  difficult 
to  cure;  but  when,  commencing  gradually,  it  has  at  length  come 
to  disorder  the  whole  system,  it  rarely  terminates  favorably,  and 
must  be  ranked  among  the  most  rebellious  of  maladies.  It  not 
unfrequently  remains  stationary  for  a  time,  or  even  almost 
entirely  disappears,  and  then  recurs,  perbaps  with  increased 
violence,  merely  from  the  slightest  irregularity  in  diet,  drinking 
a  glass  of  wine,  exposure  to  cold,  fatigue,  or  venereal  indulgence. 
The  prognosis  is  always  more  unfavorable  in  old  tban  in  young 
subjects,  in  protracted  than  in  recent  cases,  and  in  the  simple 
than  in  the  complicated  forms  of  the  disease.  "When  the  kidneys, 
ureters,  prostate  gland,  or  urethra  are  much  involved,  the  com- 
plaint generally  proves  fatal  under  the  best  management,  the 
patient  being  gradually  worn  out  by  local  suffering  and  consti- 
tutional irritation. 

The  morbid  alterations  observed  in  those  who  die  of  this  dis- 
ease are  various.  In  the  early  stage,  and  in  the  milder  forms, 
the  mucous  membrane  is  in  a  state  of  passive  hyperemia,  and 
the  subepithelial  connective  tissue  is  tumid  and  infiltrated  with 
cells.  Later  in  the  disease,  ulceration  is  not  uncommon;  and 
hypertrophy  of  the  bladder  is  almost  invariably  present.  Saccu- 
lation of  the  viscus  is  not  infrequent,  and  the  kidneys,  ureters, 
and  prostate  are  generally  implicated.  Now  and  then,  as  was 
first  noticed  by  Rokitansky,  there  is  an  excessive  growth  of 
tessellated  epithelium  on  the  surface  of  the  mucous  membrane, 
which  leads  to  the  formation  of  thickly-laminated,  whitish, 
glistening  layers  of  epithelial  cells,  wbich  become  detached  in 
large  scales.     These  cells  may  undergo  fatty  degeneration,  and 


48  CHRONIC    INFLAMMATION    OF    THE    BLADDER. 

crive  rise  to  a  singular  condition  which  was  observed  by  Lowen- 
son,^  in  a  female,  forty  years  of  age.  The  bladder  was  enormously 
dilated,  and  iilled  with  three  and  three-quarters  of  a  pound  of 
small  yellow  globules  and  glistening  scales  lying  free  in  the 
interstices,  the  whole  looking  like  pea-soup,  witb  the  husks  re- 
tained. The  inner  surface  of  the  viscus  was  covered  with  firm, 
elastic,  laminated  flakes  of  dull  mother-of-pearl  brilliancy.  J^e 
concretions  were  formed  by  the  contractions  of  the  bl^^p 
detaching  fragments  of  tlie  fissured  deposit,  which  undei^Bfft 
fatty  metamorphosis,  their  globular  shape  being  imparted  to 
them  b}'  mutual  friction  and  attrition.  Epithelial  hyperplasia, 
with  epidermoid  transformation,  is  only  seen  as  the  result  of  fre- 
quent relapses  of  chronic  inflammation. 

In  the  treatment  of  this  aft'ection,  the  leading  indications  are, 
to  remove  the  exciting  cause,  to  allay  morbid  action,  to  prevent 
the  decomposition  of  the  urine,  and  to  keep  the  bladder  clean. 
If  there  be  a  stricture  of  the  urethra,  stone,  or  foreign  body  in 
the  bladder,  hypertrophy  of  the  prostate  gland,  or  disease  of  the 
neighboring  and  associated  organs,  neither  topical  nor  general 
remedies  can  be  of  the  least  avail,  unless  these  affections  are 
removed.  A  thorough  preliminary  examination  should  always 
be  made  of  the  urethra,  the  prostate,  the  interior  of  tlie  bladder, 
the  rectum,  the  vagina,  the  uterus  and  its  appendages,  and  the 
pelvic  cavity. 

Antiphlogistics  are  required  in  all  cases  attended  with  violent 
pain,  frequent  micturition,  and  constitutional  disturbance. 
Twenty  to  thirty  foreign  leeches  may  be  applied  to  the  peri- 
neum and  inside  of  the  thigh,  or  to  the  lower  part  of  the  hypo- 
gastrium ;  and  the  topical  bleeding  should  be  followed  up  by 
the  warm  bath,  warm  fomentations,  and  warm  enemata.  The 
bowels  must  be  opened  wntli  saline  cathartics ;  or,  when  the 
secretions  are  much  deranged,  with  blue  mass  and  podophyllin, 
with  the  addition  of  one  grain  of  ipecacuanha,  all  articles  tend- 
ing to  irritate  the  rectum  being  avoided.  Strict  recumbency 
must  be  enjoined ;  the  diet  should  be  light ;  and  demulcent 
drinks,  as  gum- Arabic,  or  slippery-elm,  water,  or  flaxseed  tea, 
should  be  freely  used. 

When,  by  these  means,  the  violence  of  the  disease  has  been 

'  Peters.  Mod.  Zeitscbr.,  2,  1863,  p.  225. 


CATARRH  OF  THE  BLADDER.  49 

subdued,  I  know  of  no  remedy  so  well  calculated,  in  ordinary 
cases,  to  ameliorate  the  morbid  condition  of  the  bladder  as  the 
balsam  of  copaiba.  To  be  effectual,  it  should  be  given  in  doses 
not  exceeding  ten,  fifteen,  or  twenty  drops,  three  or  four  times 
in  the  twenty-four  hours.  The  best  form  is  that  of  emulsion, 
prepared  with  gum  Arabic,  loaf-sugar,  and  oil  of  gaultheria. 
Its  nauseating,  griping,  and  purging  tendencies  should  be 
counteracted  by  combining  with  each  dose  a  few  drops  of  lauda- 
num, or  a  sniall  quantity  of  morphia.  When  it  does  not  dis- 
agree with  the  stomach,  or  produce  other  mischief,  its  employ- 
ment may  often  be  advantageously  persisted  in  for  several 
successive  weeks.  When  the  patient  is  troubled  Avith  pyrosis, 
or  a(^d  eructations,  the  medicine  may  be  advantageously  con- 
joined with  bicarbonate  of  soda. 

The  terebinthinate  preparations  are  sometimes  highly  bene- 
fi.cial  in  this  alfection.  They  should  be  used  in  small  doses, 
largely  diluted  with  gum-water.  The  Chian  turpentine  is,  on 
the  whole,  the  best  of  this  class  of  remedies,  exhibited  in  the 
form  of  pills,  with  extract  of  henbane,  cicuta,  or  colchicum. 

From  buchu  and  pareira  brava,  which  have  been  so  much 
extolled  in  the  treatment  of  catarrh  of  the  bladder,  I  have  never 
derived  much  benefit.  An  article  which  has  a  specific  tendency 
to  the  urinary  organs,  and  which  I  have  found  particularly  ser- 
viceable in  cases  attended  with  excessive  morbid  sensibility  of 
the  neck  of  the  bladder,  is  uva  ursi.  It  may  advantageously  be 
conjoined  with  hops  or  lupuline,  and,  in  the  class  of  cases  just 
mentioned,  with  bicarbonate  of  soda.  The  combination,  which 
I  am  in  the  habit  of  using,  consists  of  one  ounce  and  a  half  of 
the  leaves  of  the  uva  ursi,  and  half  an  ounce  of  hops,  or  one 
drachm  of  lupuline,  infused  in  a  quart  of  water  in  a  covered 
ves8el  for  two  hours.  To  the  strained  liquor  are  added  two 
drachms  of  bicarbonate  of  soda,  and  two  grains  of  morphia,  if 
there  be  much  pain.  Of  this  a  wineglassful  is  to  be  taken  five 
or  six  times  a  day. 

The  epigwa  repens,  commonly  called  the  trailing  arbutus, 
ground-laurel,  or  May-flower,  may  occasionally  prove  useful  in 
this  malady.  It  possesses  moderately  diuretic,  as  well  as  slightly 
astringent,  properties,  and  is  closely  allied,  in  its  efiects  upon  the 
urinary  organs,  to  uva  ursi.  The  best  form  of  exhibition  is  a 
strong  decoction,  prepared  with  one  ounce  of  the  dried  leaves  to 
4 


50  CHROXIC    INFLAMMATION    OF    THE    BLADDER. 

a  pint  of  water,  of  which  a  large  wineglassful  may  be  taken 
every  two  or  tliree  hours.  Sir  Henry  Thompson  speaks  highly 
of  triticum  repens,  or  couch  grass,  in  this  aftection.  Two  ounces 
of  the  cut  and  dried  underground  stem  are  boiled  in  one  pint  of 
water  for  fifteen  minutes.  The  strained  infusion  is  given  in 
doses  of  a  gill  four  times  during  the  twenty-four  liours. 

A  combination  of  some  of  the  articles  above  mentioned  may 
often  be  advantageously  employed.  Indeed,  the  effect  is  usually 
much  more  conspicuous,  when  they  are  given  in  this  manner, 
than  when  they  are  used  separately.  I  have  long  been  in  the 
habit  of  administering,  with  the  happiest  effect,  a  combination 
of  buchu,  uva  ursi,  and  cubebs,  sometimes  in  the  form  of  infu- 
sion, but  more  generally  in  that  of  tincture,  given  several  times 
a  day  in  conjunction  with  a  small  quantity  of  bicarbonate  of 
soda.  Occasionally,  a  few  drops  of  balsam  of  copaiba,  tincture  of 
the  chloride  of  iron,  or  dilute  nitric  acid,  may  be  advantageously 
added  to  each  dose  of  these  medicines.  When  thus  combined, 
it  is  of  course  impossible  to  determine  what  merit  is  due  to  each 
respective  article.  The  tincture  of  the  chloride  of  iron,  given 
by  itself,  sometimes  answers  an  excellent  purpose.  It  is  a 
valuable  tonic,  and  evidently  exerts  a  direct  influence  upon 
the  urinary  organs.  Its  use  is  particularly'  indicated  in  cases 
attended  with  atony  of  the  bladder,  a  want  of  appetite,  loss  of 
strength,  and  great  pallor  of  the  countenance.  When  the  dis- 
ease is  associated  with  a  gouty  or  rheumatic  state  of  the  system, 
colchicum  should  be  employed,  and  the  best  form  of  exhibiting 
it  is  in  combination  with  an  anodyne.  My  usual  practice  is  to 
give  one  drachm  of  the  vinous  tincture  with  fifty  drops  of  lauda- 
num, or  half  a  grain  of  morphia,  every  night  at  bedtime,  fol- 
lowed every  other  morning  by  a  small  quantity  of  Epsom  salt 
and  calcined  magnesia,  to  clear  out  the  bowels  gently.  In  some 
instances,  the  acetic  extract,  in  the  dose  of  two  grains,  forms  a 
valuable  substitute. 

Benzoic  acid  is  sometimes  used  in  this  disease,  and  occasion- 
ally answers  when  everything  else  has  failed.  I  have  repeatedly 
employed  it  with  excellent  effects,  and  can  speak  positively  as 
to  its  v^lue  in  the  treatment  of  cystorrhoea.  It  may  be  given 
by  itself,  or  what  I  prefer,  in  union  with  balsam  of  copaiba.  It 
occasionally  acts  like  a  charm.  Its  value  arises  from  the  fact 
that  it  neutralizes  the  carbonate  of  ammonia  of  the  decomposed 


CATAREH  OF  THE  BLADDER.  51 

urine,  forming  a  soluble  hippurate  of  ammonia,  which  prevents 
the  deposition  of  triple  phosphates.  The  dose  is  fifteen  grains 
dail}^  gradually  increased  to  one  drachm,"  in  the  form  of  pills, 
or  suspended  in  mucilage  of  gum  Arabic.  By  the  employment 
of  this  remedy,  the  acid  reaction  of  the  urine  is  restored  in  a 
week  or  ten  days. 

To  allay  pain  and  induce  sleep,  anodynes  are  indispensable  in 
almost  every  stage  of  this  disease.  They  should  be  given  in  full 
doses  by  the  mouth,  by  the  rectum,  or  hypodermically.  An 
injection,  composed  of  from  one  to  two  drachms  of  tincture  of 
opium  and  two  ounces  of  starch  w^ater,  often  powerfully  contri- 
butes to  allay  the  pain  and  spasm  of  the  bladder.  An  anodyne 
suppository  not  unfrequently  answers  the  purpose  much  better 
than  an  enema.  It  exerts  the  same  calming  influence,  and  pos- 
sesses the  additional  advantage  that  it  does  not  stimulate  the 
rectum  to  throw  off  its  contents.  An  excellent  suppository  con- 
sists of  two  grains  of  opium,  and  five  grains  of  camphor,  with 
half  a  grain  of  extract  of  belladonna,  rul)bed  up  with  cacoa 
butter.  When  a  diaphoretic  eftect  is  desired  along  with  the 
anodyne,  the  most  efiicient  remedies  that  can  be  employed  are 
Dover's  powder,  or  morphia  with  tartar  emetic. 

Counter-irritation,  in  the  form  of  an  issue,  with  the  hot  iron, 
tartar  emetic  pustulation,  or  strong  tincture  of  iodine,  applied 
to  the  hypogastrium  and  the  perineum,  is  sometimes  useful,  par- 
ticularly in  obstinate  cases.  An  emollient  poultice  sprinkled 
with  mustard,  or  flannel  cloths  wrung  out  of  hot  water  and 
laudanum,  laid  over  the  pubes,  are  often  productive  of  tempo- 
rary benefit. 

The  last  and  one  of  the  most  important  indications  in  the 
treatment  of  cystorrhoea,  is  fulfilled  by  emptying  the  bladder  of 
its  residual  acrid  and  irritating  urine  with  the  catheter,  and 
freeing  its  lining  membrane  from  viscid  and  earthy  deposits  by 
thoroughly  washing  out  its  interior,  twice  daily,  w^ith  water  at 
a  temperature  of  98°  or  100°.  Caution  must  be  observed  in 
resorting:  to  these  measures  as  Ions;  as  the  viscus  resents  the 
introduction  of  instruments,  lest  greater  injury  be  inflicted,  and 
a  remedy,  otherwise  calculated  to  be  beneficial,  be  brought  into 
disre[iute.  Under  these  circumstances,  however,  pain  from 
instrumental  contact  may  be  avoided  by  using  a  gum  elastic 
catheter  provided  with  an  opening  at  its  extremity  instead  of  on 


52 


CHRONIC    INFLAMMATION    OF    THE    BLADDER. 


its  side.  This  slionld  be  withdrawn,  as  the  last  drops  of  urine 
are  passing  off,  so  that  it  may  rest  merely  at  the  vesical  orifice 
of  the  urethra,  when  about  an  ounce  of  water  is  thrown  in  by 
an  India-rubber  bag,  with  a  stopcock  and  tapering  nozzle,  the 
latter  of  which  is  inserted  into  the  catheter.  By  entering  the 
instrument  a  little  way,  the  dirty  fluid  readily  escapes ;  and 
the  operation  is  repeated  five  or  six  times,  or  until  the  water 
comes  away  nearly  clear.  Instead  of  this  simple  apparatus,  the 
self-injecting  device  of  Dr.  E.  L.  Keyes,  of  New  York,  shown  in 
fig.  2.  will  be  found  to  answer  an  admirable  purpose.     Should 


Keyes'g  Apparatus  for  Washing  out  the  Bladder. 

the  prostatic  urethra  be  sensitive,  the  catheter  need  oidy  be 
passed  through  the  opening  in  the  triangular  ligament.  Indeed, 
the  bladder  may  be  injected  by  inserting  an  instrument  only  an 
inch  or  two  in  the  canal.  For  this  purpose  Professor  Zeissl,i 
of  Vienna,  after  having  placed  the  patient  recumbent,  with  the 
pelvis  elevated,  grasps  the  penis  with  the  left  hand,  putting  it 

'  Prager  Vierteljahrschrift,  Bd.  ii.,  1875,  p.  62. 


CATAERH  OF  THE  BLADDEE.  53 

on  the  stretch,  and  carrying  it  at  the  same  time  towards  the 
abdomen,  while,  with  the  right  hand,  he  inserts  a  gum-elastic 
tube  into  the  meatus,  the  other  end  of  which  is  attached  to  a 
bag  filled  with  fluid,  and  elevated  several  feet  above  the  level 
of  the  patient's  body. 

In  whatever  way  the  injection  be  practised,  the  utmost  care 
and  gentleness  must  be  observed  ;  and  air  must  not  be  permitted 
to  enter  the  bladder,  as  it  would  produce  severe  pain.  When 
the  urine  is  highly  alkaline  and  fetid,  the  water  may  be  impreg- 
nated with  chloral  hydrate,  permanganate  of  potassa,  or  carbolic 
acid ;  and  with  a  view  of  making  a  direct  impression  on  the  in- 
flamed surface,  when  it  resists  simple  treatment,  astringent, 
sedative,  and  alterant  agents  may  advantageously  be  used.  Of 
these  the  most  important  are  acetate  of  lead,  sulphate  of  zinc, 
nitrate  of  silver,  borax,  morphia,  and  nitric  acid.  Of  the  first 
three  articles  the  proper  proportion,  to  begin  with,  is  about  one- 
fourth  of  a  grain  to  the  ounce;  of  borax  fifteen  grains  ;  of  mor- 
phia one  grain  ;  and  of  nitric  acid  two  drops.  The  latter  agent 
and  the  metallic  salts  are  most  useful  when  the  urine  is  deposit- 
ing phosphates.  The  article  which,  on  the  whole,  I  have  myself 
found  most  eflicacious  is  nitrate  of  silver  in  union  with  one 
draclim  of  laudanum.  Tlie  fluid  should  be  retained  until  it 
causes  uneasy  sensations,  or  a  feeling  of  distention,  when  it 
should  be  removed.  I  have  never  employed  strong  injections 
of  this  salt,  as  from  twenty  to  thirty  grains  to  the  ounce  of 
water,  having  always  been  afraid  of  the  results  of  such  heroic 
doses.  In  very  troublesome  cases.  Dr.  Mac  Donnell,  of  Montreal, 
with  whom  the  practice  appears  to  have  originated,  derived 
great  benefit  from  nitrate  of  silver,  in  the  proportion  of  four 
grains  to  the  ounce,  repeated  once  a  week ;  and  Dr.  J.  Braxton 
Hicks,^  of  Guy's  Hospital,  has  quite  recently  recommended  a 
solution  of  from  five  to  fifteen  grains,  following  it  up  Avith  a 
permanent  injection  of  two  grains  of  morphia  to  the  ounce  of 
water. 

Cauterization  with  the  solid  nitrate  of  silver  has  been  resorted 
to  especially  by  Civiale  and  other  French  surgeons.  I  have  made 
a  trial  of  the  remedy  in  a  few  instances ;  but  do  not  think  it 
made  any  decided  impression  upon  the  disease.     It  is  chiefly 

'  British  Med.  Journ.,  vol.  ii.,  1874,  p.  30, 


54  CURONIC    INFLAMMATION    OF    THE    BLADDER. 

applicable  to  those  cases  in  which  the  catarrh  is  dependent  upon 
inflammation  of  the  neck  of  the  bladder,  accompanied  with  an 
unusual  degree  of  morbid  sensibility.  The  oi:)eration,  which 
should  be  repeated  once  everj'  sixth  or  seventh  day,  is  best  per- 
formed with  a  common  portc-eaustique,  the  cup  of  which  is 
rapidly  passed  over  the  affected  surface,  and  then  withdrawn. 

In  obstinate  and  intractable  cases  of  cystorrhoea,  where  all 
other  remedies  have  failed  to  afford  relief,  it  has  been  proposed 
to  open  the  neck  of  the  bladder  by  means  of  an  incision,  similar 
to  that  made  in  the  lateral  operation  of  lithotomy,  or  by  colpo- 
cystomy  in  the  female,  as  previously  described  in  the  section  on 
ulceration  of  the  bladder.  The  object  is  to  afford  a  free  outlet 
to  the  altered  secretion  as  fast  as  it  takes  place,  and  thereby  put 
the  organ  into  a  state  of  comparative  repose.  This  procedure, 
which  was  originally  suggested  by  Mr.  Guthrie,  of  London,  was 
first  carried  into  effect,  in  1850,  by  Dr.  Willard  Parker,  of  l!^ew 
York,  and  has  been  resorted  to,  in  the  last  decade,  by  Dr.  E. 
Powell,  of  Cliicago,  Dr.  Robert  Battey,  of  Georgia,  and  Dr. 
Gouley,  of  N'ew  York.  In  the  case  of  Dr.  Battey  life  was  pro- 
longed in  a  state  of  comparative  comfort  for  eighteen  months. 
The  patient  of  Dr.  Gouley  was  well  and  stout  three  years  after 
the  o[ioration,  with  a  permanent  fistule,  for  which  he  wore  a 
urinal.  The  practice  certainly  deserves  imitation ;  and  is 
particularly  applicable  to  that  form  of  cystorrlioea  in  which 
there  is  marked  hypertro[)hy  of  the  prostate,  or  in  Avliieh  there 
is  concentric  hj-pertrophy  with  diminished  capacity  of  the 
bladder. 

Finally,  in  the  management  of  this  affection  the  utmost  atten- 
tion must  be  paid  to  the  diet,  which  should  be  of  a  farinaceous 
character,  perfectly  simple,  and  unirritant.  During  the  existence 
of  a  paroxysm  of  the  disease,  nothing  but  arrowroot,  tapioca, 
sago,  rice,  or  gruel,  should  be  allowed,  and  that  only  in  small 
quantit}'.  As  the  sjmiptoms  disappear,  or  when  convalescence 
is  fairly  established,  animal  broths,  fresh  fish,  oysters,  and  a 
little  of  the  lighter  kinds  of  meat,  may  be  used.  But  neither 
at  this  nor  at  any  previous  period  are  condiments,  as  mustard 
and  pepper,  admissible.  Even  salt  should  be  employed  most 
sparingly.  The  slightest  indiscretion  in  eating  will  be  almost 
certain  to  be  followed  by  an  aggravation  of  the  complaint,  or  a 
return  of  all  the  former  symptoms.     Vegetable  acids,  subacid 


HYPERTROPHY  OF  THE  BLADDER.  55 

fruits,  wine,  spirits,  and  fermented  liquors  are  prejudicial,  and 
must  be  abstained  from.  The  best  drink  is  cold  water,  either 
simple  or  rendered  mucilaginous  with  gum  Arabic,  elm  bark,  or 
flaxseed.  When  there  is  decided  debility,  the  mineral  acids, 
quinine,  iron,  and  the  bitter  infusions,  are  indicated. 

Exposure  to  cold  nmst  be  carefully  guarded  against.  Flannel 
must  be  worn  next  the  skin,  both  summer  and  winter;  riding 
on  horseback  is  to  be  interdicted  ;  sexual  intercourse  is  to  be 
abstained  from ;  and  the  bladder  must,  for  a  long  time,  be  emptied 
daily  at  stated  intervals.  A  residence  in  a  warm  climate  some- 
times exerts  a  happy  influence.  Several  of  my  patients  have 
derived  signal  benefit  from  spending  their  winters  in  New 
Orleans,  Cuba,  Florida,  and  Texas. 

When  the  kidneys,  ureters,  or  prostate  gland  are  seriousl}^ 
aftected,  no  remedy,  external  or  internal,  local  or  constitutional, 
seems  to  have  the  power  of  checking  this  distressing  malady. 
Life  gradually  ebbs  awa}',  and  the  patient  dies  completely  ex- 
hausted. All  we  can  advise,  under  such  circumstances,  is  perfect 
tranquillity,  a  liglit  but  generous  diet,  anodynes  by  the  mouth 
and  the  rectum,  the  warm  bath,  and  attention  to  the  bowels. 
Occasionally  an  accidental  hemorrhage  occurs,  and  procures  a 
temporary  suspension  of  the  suflering. 

Sect.  II  — HYPERTKOPHY  OF  THE  BLADDER. 

Of  the  various  morbid  alterations  associated  with  chronic 
inflammation  of  the  bladder,  especially  when  it  is  dependent 
upon  stricture  of  the  urethra,  enlargement  of  the  prostate, 
calculus,  and  neoplasms,  by  far  the  most  frequent  is  general 
and  unmixed  hypertrophy  of  its  walls,  as  shown  in  fig.  3,  from 
a  specimen  in  my  collection.  Although  it  may  be  seated  in 
any  of  the  tunics,  the  hypertrophy  is  most  common  in  the  mus- 
cular, converting  it  into  a  homogeneous,  grayish-red  fleshy  mass, 
which  sometimes  acquires  the  thickness  of  half  an  inch,  or  even 
one  inch,  in  consequence  of  the  powerful  and  frequent  eftbrts 
it  is  obliged  to  make  to  overcome  the  mechanical  obstruction  to 
the  egress  of  the  urine,  whereby  its  nutrition  is  greath^  increased. 
The  lesion  is  often  partial,"  or  limited  to  the  internal  fibres  of  the 
detrusor  muscle,  which  arc  collected  into  large,  rounded,  pro- 
jecting fasiculi,  and  resemble  the  fleshy  columns  of  the  ventricles 


56 


CHRONIC    IXFLAMMATIOX    OF    THE    BLADDER. 


Fig-  3.  of  tlie  heart,  thereby  constitut- 

'  '*^*^.>_.  ing  the  condition  known  as  the 

_    _  ^  cohminiform  bladder,  and  giv- 

ing rise  to  the  peculiar  retiform 
arrano-ement  which  is  so  well 
exhil)ited  in  fig.  4,  from  a  pre- 
paration in  my  private  cabinet. 
The  capacity  of  the  viscus,  in 
the  majority  of  eases,  is  some- 
what increased,  in  consequence 
of  the  accumulation  of  its  con- 
tents, and  partial  loss  of  power 
to  expel  them.  AVhen  the 
trouble  arises  from  obstruction 
to  the  free  passage  of  the  urine 
from  enlargement  of  the  pros- 
tate in  aged  persons,  enormous 
dilatation  is  sometimes  conjoined  with  hypertroi>hy  of  the 
muscular  fibres,  which  are  in  a  more  or  less  advanced  state  of 
fatty  degeneration,  the  bladder  rising  high  up  into  the  cavity 
of  the  abdomen,  and  containing  many  pints  of  urine.     I  have 


General  Hypertrophy  of  the  Bladder. 


ColamDiform  Bladder. 


in  my  possession  several  beautiful  illustrations  of  this  condition. 
Eccentric  hypertrophy  may  even  be  congenital,  and  the  dilatation 


HYPEETROPHY  OF  THE  BLADDER.  57 

be  so  ffreat  as  to  be  a  cause  of  obstructed  labor.  In  a  remarkable 
case  of  this  nature,  reported  by  M,  Dcpaul,  in  which  a  six 
months'  foetus  had  to  be  removed  by  embryotonw,  the  bladder 
filled  nearly  the  entire  belly,  and  measured  fourteen  inches 
in  its  largest  circumference,  the  immediate  cause  of  the  trouble 
having  been  obliteration  of  a  portion  of  the  canal  of  the  urethra. 
It  is  interesting  to  note,  in  connection  with  this  case,  that  the 
liypertrophy  of  the  mus(;ular  walls  denotes  that  the  foetal 
Ijladder  does  not  merely  play  a  passive  role,  but  endeavors  to 
expel  its  contents.  In  an  opposite  class  of  cases,  particularly 
where  there  has  been  great  irritability  and  spasm,  as  fi-om  the 
presence  of  a  stone,  or  an  irritable  stricture  of  the  urethra,  the 
cavity  of  the  bladder  is  much  contracted,  giving  rise  to  con- 
centric hypertrophy,  and  as  a  natural  result,  if  the  barrier  to 
the  escape  of  the  urine  be  great,  to  the  accumulation  of  that 
fluid  in  the  ureters  and  the  kidneys,  which  accordingly  become 
enormously  enlarged. 

Hypertrophy  of  the  bladder  is  essentially  a  disease  of  adults, 
and,  for  obvious  reasons,  is  far  more  common  in  men  than  in 
women.  It  is,  however,  not  infrequent  in  young  children 
suffering  from  phimosis,  and  presenting  all  the  symptoms  of 
calculus,  and  I  have  met  with  several  instances,  in  impubic 
subjects,  in  which  the  projecting  fibres  were  covered  with  phos- 
phatic  deposit.  The  aftection  may  exist  at  an  early  age  without 
any  obstruction  whatever,  in  consequence  of  unhealthy,  but  too 
frequent  and  forcible,  action,  the  symptoms  being  those  of  ex- 
cessive vesical  irritability.  Examples  of  this  nature  are  recorded 
by  Sir  James  Paget.^ 

It  is  a  familiar  fact  that  hypertrophy  of  the  bladder  in  adults 
may  arise  from  the  want  of  consentaneous  action  between  the 
detrusor  muscle  of  the  bladder,  and  the  compressor  muscle  of 
the  urethra.  In  the  event  of  the  failure  of  the  latter  to  relax 
when  the  former  contracts,  the  organ  must  of  necessity  be  sub- 
jected to  more  frequent,  violent,  and  irregular  exertions  to  void 
its  contents,  through  which  its  muscular  walls  finally  become 
hypertrophied.  In  this  way  a  species  of  retention  of  urine  is 
brought   about,  giving    rise    to  what  Sir  James   Paget^  terms 

'  Lectures  ou  Surgical  Patliolosy,  3d  ed.,  pp.  56  and  57. 
2  Clinical  Lectures  and  Essays,  1875,  p.  77. 


58 


CHRONIC    INFLAMMATION    OF    THE    BLADDER. 


stammering  bladder,  an  example  of  winch,  from  defective  voli- 
tion, is  narrated  in  the  chapter  on  Retention  of  Urine.  I  am 
acquainted  with  a  young  gentleman  in  whom  an  attack  of  stam- 
mering is  induced  b}'  the  whistling  of  a  person  detecting  him 
in  the  act  of  urination. 

When  the  hypertrophy  is  seated  in  the  lining  membrane,  or 
in  the  subjacent  fibrous  tissue,  there  is  generally  an  excessive 
development  of  the  mucous  follicles,  which  are  rendered  extremeh' 
prominent,  and  pour  out  an  uiuisual  amount  of  thick,  ropy  fluid. 
In  some  instances  callosities,  due  to  hj'perplastic  formation  of 
young  connective  tissue,  are  met  with. 

The  mucous  membrane,  or  this  structure  and  the  subjacent 
fibrous  and  superficial  muscular  textures,  is  sometimes  elevated 
into  one  or  more  transverse  ridges  or  bars,  of  which  there  are 
several  distinct  varieties.  In  a  preparation  in  the  cabinet  of  Dr. 
Sabine,  from  which  the  annexed    drawing,  fig.  5,  was   taken, 

Fiff.  5. 


Interuieteral  Bar. 


there  are  two  ridges,  of  which  the  anterior  and  larger,  «,  over- 
hangs the  trigone,  and  corresponds  to  the  interureteral  ligament, 
of  which  it  is  merely  an  exaggerated  condition.  The  ureters 
themselves,  6,  6,  opeu  on  the  front  of  the  bar,  about  one-third  of 
an  inch  from  its  rounded  extremities.  The  walls  of  the  bladder 
are  upwards  of  half  an  inch  in  thickness,  and  the  prostate  is  more 
than  three  times  its  natural  size.  The  middle  lobe  of  the  gland 
is  greatly  enlarged,  and  consists  of  three  distinct  masses,  separated 
by  deep  grooves ;  they  are  rounded  off  behind,  where  they  are 
in  contact  with  the  main  ridge  of  the  bladder,  while  they  are 
quite  slender  and  narrow  in  front.  Almost  precisely  similar 
appearances  are  exhibited  in   tig.  3.      The  presence  of  such  a 


HYPERTKOPHY  OF  THE  BLADDER.  59 

ridge  naturally  tends  to  dam  up  the  urine  in  the  bas-fond  of  the 
bladder,  and  to  keep  up  a  constant  state  of  chronic  inflammation. 
It  may  also  give  rise  to  trouble  in  finding  a  calculus,  after 
lithotomy,  as  in  an  interesting  case  reported  b}^  Mr.  Bicker- 
steth.i 

Another  and  entirely  distinct  variety  of  the  aflt'ection  was  first 
accuratel}^  described  by  ]Mr.  Guthrie,^  under  the  name  of  the  bar 
at  the  neck  of  the  bladder.  The  affection  includes  two  opposite 
conditions  ;  the  first,  and  b}-  far  the  more  unconmion,  being  a 
crescentic,  valvular  fold,  or  transverse  ridge,  at  the  neck  of  the 
reservoir,  due  to  hypertrophy  of  the  mucous  membrane  and 
muscular  fibres  which  constitute  the  uvula,  and  entirely  indepen- 
dent of  prostatic  enlai'gement ;  while  the  second  is  due  to  a 
barrier  formed  by  a  fold  of  the  lining  membrane,  perhaps  including 
some  fibrous  and  muscular  elements,  lifted  upward  by  the  enlarged 
lateral  lobes  of  the  gland.  In  another  class  of  cases,  the  bar  is 
dependent  upon  hypertrophy  of  the  median  portion  of  the  pros- 
tate. 

The  simple  form  of  this  variety  of  hypertrophy  is  occasionally 
observed  in  comparatively  early  life ;  while  the  prostatic  form 
occurs  in  old  men  who  have  labored  for  a  long  time  under  vesical 
irritation.  The  former  is  produced  by  inflammation  of  the  neck 
of  tlie  bladder  from  gonorrhcea,  or  other  excitants  of  chronic 
spasmodic  action  which  terminate  in  conti'action  and  hypertrophy 
of  the  muscular  fibres  in  this  situation.  Viewed,  then,  in  refer- 
ence to  its  causation,  it  may  be  the  result  of  anj-  aftection  attended 
with  obstruction  to  the  evacuation  of  the  urine,  and  the  habitual 
retention  of  this  fluid  in  the  bladder.  Hence  the  most  common 
exciting  causes  are  such  as  produce  general  hj'pertrophy  of  the 
organ. 

The  symptoms  of  hypertrophy  of  the  bladder  are,  in  all  respects, 
similar  to  those  which  indicate  mechanical  obstruction  to  the 
flow  of  urine  and  chronic  c\^stitis.  In  the  bar-like  variety  of 
the  aftection,  the  patient  is  also  harassed  with  pain,  particularly 
severe  at  the  neck  of  the  viscus,  and  excessive  straining  and 
tenesmus,  accompanied  by  a  scalding  or  burning  sensation  of  the 
urethra,  at  every  attempt  at  micturition.     There  are,  however, 

'   Liverpool  Medical  and  Surgical  Reports,  vol   i  ,  1867. 
2  Diseases  of  the  Bladder  aud  Urethra,  1834. 


60  CHRONIC    INFLAMMATION    OF    THE    BLADDER. 

unfortunately  no  reliable  signs  of  this  lesion.  In  all  cases,  a 
careful  exploration  with  the  linger  and  sound  should  he  insti- 
tuted, as  most  likely  to  clear  up  the  obscurities  environing  the 
diagnosis.  A  sound,  with  a  short  beak,  will  readily  pass  as  far  as 
the  vesical  orifice  of  the  bladder,  where,  meeting  with  the  bar, 
it  will  be  partially  or  even  completely  arrested,  or  have  to  be 
lifted  over  it.  The  beak  of  the  instrument  being  in  contact 
with  the  barrier,  if  the  finger  be  introduced  into  the  rectum, 
and  carried  as  high  up  as  possible,  its  point  may  touch  the 
posterior  surface  of  the  bar,  which  being,  in  this  way,  included 
between  the  finger  and  the  sound,  a  good  idea  of  its  form  and 
dimensions  may  be  arrived  at.  If  the  sound  is  now  passed 
onwards  into  the  bladder,  and  its  beak  turned  downwards, 
attempts  at  its  removal  will  be  futile,  as  it  will  hook  against 
the  ridge  in  that  position. 

The  treatment  of  general  hypertrophy  of  the  bladder  need  not 
be  dwelt  upon,  as  it  consists  essentially  in  the  removal  of  its 
exciting  cause,  the  regular  use  of  the  catheter,  and  washing  out 
the  bladder  at  stated  intervals.  In  the  bar-like  form  of  the 
affection,  the  catheter  ma}^  be  permitted  to  remain  permanently 
in  the  bladder,  as  its  pressure  may  exert  a  sorbefacient  efiect,and 
aid  in  reducing  the  volume  of  the  bar.  Cauterization  of  the 
part  with  the  author's  instrument  will  generally  allay  the  heat 
and  burning  pain,  and  exert  a  direct  and  controlling  influence 
over  the  concomitant  morbid  action  of  the  mucous  membrane  in 
the  immediate  vicinity  of  the  bar.  The  operation  is  performed 
with  great  gentleness,  yet  efficiently,  and  in  such  a  manner  as 
to  bring  the  nitrate  of  silver  in  contact  with  a  surface  at  least 
from  one  to  two  inches  in  diameter.  The  local  irritation  and 
distress  are  temporarily  increased,  but  they  subside  in  a  few 
hours,  and  never  fail  to  be  followed  by  marked  relief,  although 
frequently  not  until  the  patient  has  taken  a  full  anodyne.  The 
cauterization  is  repeated  every  sixth  or  eighth  day,  and  in  the 
interval  the  patient  is  subjected  to  the  treatment  prescribed  for 
chronic  cystitis. 

Division  of  the  bar,  as  originally  practised  by  Mr.  Guthrie, 
and  extensively  adopted  by  the  French  surgeons,  may  be  resorted 
to  when  more  simple  measures  fail  to  aftbrd  relief.  The  opera- 
tion is  most  conveniently  performed  by  the  instrument  of  Mr. 
]\Iercier,  depicted  in  fig.  6.     It  consists  of  a  silver  canula,  con- 


HYPERTROPHY    OF    THE    BLADDER. 


61 


Fiff.  6. 


taining  a  blade,  which,  by  means  of  the  circular  handle,  is  made 
to  cut  from  before  backwards,  or  from  behind  forwards,  the 
extent  to  which  the  blade  is  made  to  project  being 
regulated  by  the  screw  attached  to  the  canula. 
When  the  bar  is  thick  and  rounded,  excision  of  a 
portion  may  be  practised,  as  recommended  by 
Mercier,  the  beak  of  whose  instrument  for  this 
purpose  is  shown  in  fig.  7.  A  portion  of  the 
barrier  having  been  seized  by  the  blades  of  the 
beak,  turned  downwards,  it  is  fixed  by  means  of 
the  arrow-headed  needle,  when  the  blades  are 
closed,  and  the  excised  piece  removed  when  the 
instrument  is  withdrawn.  Troublesome  hemor- 
rhage is  liable  to  follow  the  operation,  but  it  is 
rarely  a  cause  of  death.  The  subsequent  treatment 
consists  in  the  introduction  of  a   soft  catheter, 


Fiff.  7. 


re 


Mercier  s  Instrument  for  Excising  a  portion 
of  the  Bar  at  the  Neck  of  the  Bladder. 


Merciei-'s  Instrument  for 
Incising  the  Bar  at  the  Neck 
of  the  Bladder. 


commencing  on  the  sixth  day;  and  four  or  five  days  later, 
passing  a  steel  stylet  into  the  catheter  in  order  to  make  pressure 
upon  the  wound  and  prevent  its  closure. 

AVhen  there  is  no  other  prospect  of  relief,  Mr.  Guthrie  thinks 
we  should  aflbrd  the  patient  the  benefit  of  an  operation,  similar 
to  that  which  is  practised  for  the  removal  of  stone.     To  such 


62 


CHEONIC    INFLAMMATION    OF    THE    BLADDER. 


a  procedure  I  can  see  no  possible  objection;  the  parts  must  be 
relieved,  or  deatli  will  be  inevitable.  The  ojieration  itself  does 
not  involve  any  special  danger,  the  bleeding  Avhich  attends  it 
will  remove  vascular  engorgement,  and  the  muscular  fibres  of 
the  bladder  will  be  placed  in  a  quiescent  condition,  highly  favor- 
able to  the  subsidence  of  chronic  irritation.  The  urine  and 
mucus  will  flow  off  involuntarily,  and,  unless  the  wound  be 
permitted  to  heal  too  soon,  a  new  and  more  healthy  action  wall 
be  almost  sure  to  follow.  I  should  myself  certainly  prefer  this 
procedure  to  that  of  excision  of  a  portion  of  the  bar. 


Sect.  Ill  —SACCULATION  OF  THE  BLADDEE. 

Sacculation  of  the  bladder,  an  affection  which  has  also  been 
denominated  hernia  of  the  mucous  membrane,  internal  cystocele, 
encysted,  and  diverticulated  bladder,  is  a  protrusion  of  the  lining 
membrane  through  an  abnormal  opening  in  the  muscular  tissue, 

Fig.  8. 


Section  of  the  Bladder  and  Prostate,  a  Mucous  surface  of  the  bladder.  6, 6.  Laterallobes  of  the 
prostate,  e.  Middle  lobe.  d.  Large  C7st  or  pouch,  partially  laid  open,  and  communicating  wiih 
the  bladder  by  a  small  orifice.     From  a  preparation  in  my  prirate  collection. 

and  the  consequent  development  of  a  pouch,  bag,  or  sac,  wliieh 
communicates  with  the  interior  of  the  viscus. 

The  affection  is  nmch  more  frequent  than  is  generally  sup- 
posed.    I  have   repeatedly  met  with  it   in  my  own  dissections, 


SACCULATION  OF  THE  BLADDER, 


63 


unci  there  is  hardly  a  practitioner  of  much  experience  who  does 
not  occasionally  see  a  case  of  it. 

These  pouches  vary  much  in  number,  size,  and  form,  as  well  as 
in  their  structure,  and  the  character  of  their  contents.  Some- 
times there  is  only  one  ;  and  should  this  be  of  large  size,  it  may 
give  the  organ  the  appearance  of  being  double,  as  is  well  shown 
in  fig.  9,  from  a  drawing  made  by  Dr.  Gould,  of  a  remarkable 


Fiff.  9. 


Sacculated  Bladder,     a.  The  bladder,     b.  The  sac. 

Specimen  contained  in  the  Anatomical  Museum  of  the  Boston 
Society  for  Medical  Improvement.  The  supplementary  cavity, 
which  occupied  the  posterior  portion  of  the  organ,  was  capable 
of  holding  from  one  to  two  quarts  of  liuid,  and  communicated 
with  the  bladder  by  an  oval  aperture,  one  inch  and  a  half  in 
length. 

The  greatest  number  I  have  seen  was  six.  Generally  there 
are  not  more  than  two,  three,  or  four.  In  a  case  described  by 
HousteP  there  were  not  less  than  thirty-eight,  all  of  them  very 
small,  and  situated  chiefly  at  the  lower  and  back  part  of  the 
bladder.  In  their  volume,  they  range  between  a  pea  and  an 
ordinary  fist.  Usually,  however,  they  do  not  exceed  that  of  a 
pigeon's  Qgg^  or  a  small  marble.  In  an  instance  reported  in 
1862,  hy  Professor  Greene,^  of  Maine,  a  sac  of  this  kind  formed 


'  Memoirs  de  TAcademie  de  Chirurgie,  t.  i.  p.  195,  1819. 

^  American  Medical  Times,  New  York,  March  29,  1862,  p.  177. 


64  CHRONIC    INFLAMMATION    OF    THE    BLADDER. 

an  immense  tumor  containing  almost  a  gallon  of  limpid  urine, 
and  seriously  encroach ing  n[»on  the  abdominal  viscera.  It  was 
composed  of  a  prolongation  of  the  mucous  and  muscular  tissues 
of  the  bladder,  and  conmiunicated  with  that  organ  on  the  left 
side,  four  inches  from  its  neck,  hy  an  opening  eighteen  lines  in 
diameter,  with  well-delined,  smooth  edges.  The  bladder  itself 
was  greatly  hypertrophied,  its  inner  surface  exhibiting  a 
columniform  appearance.  The  prostate  was  about  the  size  of  a 
common  orange.  The  patient  was  eighty-four  years  of  age,  for 
the  last  six  of  which  he  had  been  harassed  with  dysuria. 

In  their  shape  these  sacculi  are  globular,  ovoid,  pyriform,  or 
conical.  At  an  early  period  they  generally  have  thin,  transpa- 
rent walls,  formed  exclusively  by  the  mucous  and  peritoneal 
tunics ;  but  as  they  increase  in  age,  they  are  liable  to  become 
thickened,  dense,  and  opaque,  from  interstitial  or  adventitious 
deposits.  It  is  seldom  that  any  muscular  fibres  enter  into  their 
structure.  Sometimes,  although  rarely,  they  are  double,  or  divided 
into  several  compartments  by  imperfect  septa.  The  opening  of 
communication  between  the  cyst  and  the  bladder  is  usually 
round,  smooth,  polished,  and  not  larger  than  a  goose-quill. 
Occasionally,  however,  it  is  extremely  irregular,  and  so  capa- 
cious as  to  admit  a  linger,  or  a  pullet's  egg. 

These  sacs  are  usually  occupied  by  urine,  which,  from  its  pro- 
tracted sojourn  in  them,  is  liable  to  become  decomposed,  and  to 
give  rise  to  inflammation,  followed  by  a  deposit  of  mucus,  and 
even  purulent  matter.  When  they  are  very  large,  it  is  rarely 
that  they  are  completely  emptied  at  any  one  time,  and  hence 
the  same  evil  consequences  that  result  from  partial  retention  of 
urine  from  paralysis  of  the  bladder,  or  obstruction  of  the  urethra. 
It  is  well  known  that  calculous  concretions  not  infrequently 
find  their  way  into  these  abnormal  iiouches ;  and  in  some 
instances  it  is  not  improbable  that  they  are  developed  in  them. 

There  is  no  part  of  the  bladder  that  is  entirely  exempt  from 
this  morbid  change.  Most  frequently,  however,  it  is  observed 
at  its  sides  and  summit ;  for  the  reason  apparently  that  there  is 
less  pressure  here  than  in  front  and  behind,  and  consequently 
more  room  for  the  protrusion  of  the  lining  membrane.  When 
the  cysts  are  numerous,  they  occupy  different  portions  of  the 
organ,  although  sometimes  they  are  limited  to  a  particular  situa- 
tion. 


SACCULATIOX  OF  THE  BLADDER.  65 

Sacculation  of  the  bladder  is  always  associated  with,  and,  in 
fact,  directly  dependent  upon,  some  mechanical  obstruction  to 
the  ready  egress  of  the  urine.  The  most  common  causes  are 
stricture  of  the  urethra,  eidargement  of  the  prostate  gland,  and 
calculous  concretions.  Hence  the  affection  is  much  more  iVe- 
quent  in  men  than  in  women,  in  whom  there  is  rarely  much 
permanent  impediment  of  an\'  kind  to  the  emission  of  tlie  urine. 
Old  age  is  the  period  of  life  most  prone  to  it.  I  have  never  seen 
an  instance  of  it  in  a  young  subject,  though  it  may  doubtless 
occur  at  an  early  period,  especially- when  it  is  produced  by  the 
jn-esence  of  a  calculus. 

The  mode  of  origin  of  these  pouches  is  sufficiently  well  under- 
stood. The  first  step  in  their  formation  is  the  existence  of  a 
mechanical  obstruction  at  the  neck  of  the  bladder,  or  in  the 
urethra,  attended  with  more  or  less  difficulty  in  voiding  the 
urine.  As  the  obstacle  advances,  tlie  desire  to  make  water 
becomes  more  frequent,  and  the  exertion  required  to  em[)ty  the 
bladder  also  increases.  To  surmount  the  impediment,  the  mus- 
cular coat  of  the  organ  is  obliged,  every  few  hours,  to  use  the 
most  powerful  contraction,  in  consequence  of  which  its  fibres, 
naturally  more  closely  grouped  togetlier  at  some  points  than  at 
others,  gradually  separate  from  each  other,  forming  a  sort  of 
network,  the  meshes  of  which  var}',  in  the  first  instance,  from 
the  size  of  a  millet-seed  to  that  of  a  pea.  The  resistance  of  the 
muscular  tunic  being  thus  removed  in  certain  situations,  the 
mucous  membrane,  pressed  upon  on  every  side  by  tlie  distended 
bladder,  readily  enters  the  crevices,  just  alluded  to,  and,  by  a 
continuance  of  the  exciting  cause,  gradually  bulges  out  beyond 
the  level  of  the  peritoneal  surface.  The  process  by  which  these 
changes  are  accomplished  is  slow,  and  the  probability  is  that 
many  3'ears  elapse  before  the  resulting  pouches  acquire  their  ulti- 
mate limits.  Once  formed,  their  tendency  is  to  augment  with 
every  increase  of  the  local  obstacle  upon  the  presence  of  which 
their  development  depends. 

There  are  no  special  symptoms  which  can  be  regarded  as  diag- 
nostic of  sacculated  bladder.  The  only  one  upon  which  the 
slightest  reliance  can  be  placed,  in  this  res[)ect,  is  the  existence 
of  a  tumor  in  the  hypogastric  region.  When  this  is  circum- 
scribed, movable,  elastic,  and  fluctuating,  and  especially  when 
it  is  only  partially  emptied  at  each  effin-t  at  micturition,  and 
5 


66  CHRONIC    INFLAMMATION    OF    THE    BLADDER. 

again  acquires  its  former  volume  as  the  urine  accumulates  in 
the  bladder,  the  presumption  is  strong  that  there  is  a  sacculated 
condition  of  the  mucous  membrane.  The  suspicion  is  increased, 
if  not  converted  into  certainty,  when  the  swelling  disappears 
throusrh  changes  in  the  posture  of  the  patient's  body,  or  under 
the  use  of  the  catheter,  which  ma}^  sometimes,  by  a  happy  hit, 
be  passed  into  the  abnormal  pouch,  and  when  the  patient  is 
laboring  under  some  or  all  of  the  rational  symptoms  above 
specified.  Additional  evidence  will  be  afforded  if  the  sac  con- 
tains a  calculus,  which  never  varies  its  position,  but  is  always 
perceived  at  the  same  point. 

Sacculation  of  the  bladder  is  always  connected  with  hyper- 
trophy of  the  muscular  tunic,  the  fibres  of  which,  as  already 
stated,  exhibit  a  iilexiform  arrangement,  and  are  often  three  or 
four  times  the  natural  thickness.  The  mucous  membrane  and 
submucous  connective  tissue  are  also  more  or  less  altered,  the 
former  being  frequently  thrown  into  large  folds,  especially  in 
the  bas-fond  of  the  organ,  and  tlie  latter  converted  into  a  tough, 
grayish  substance,  very  difierent  from  the  healthy  texture.  The 
peritoneal  covering  is  generally  sound.  More  or  less  disease  com- 
moidy  exists  in  the  ureters  and  kidneys,  similar  to  what  occurs 
in  hypertrophy  of  the  bladder  apart  from  any  protrusion  of  the 
lining  meml)rane. 

The  prognosis  of  this  disease  is  eminently  unfavorable,  not  so 
much  on  its  own  account  as  on  that  of  the  morbid  changes  with 
which  it  is  generally  associated,  and  which  are  commonly  of  an 
incurable  nature.  Owing  to  the  peculiar  arrangement  of  the 
sacs  and  the  absence  in  them  of  muscular  fibres,  their  contents 
are  rarely,  if  ever,  entirely  expelled  ;  the  consequence  is  that 
they  soon  become  a  source  of  irritation  to  their  lining  mem- 
brane, followed  often  by  inflannnation,  and  its  ditlerent  products, 
particularly  an  inordinate  secretion  of  mucus,  or  of  mucus  and 
pus.  Sometimes  they  become  the  seat  of  a  large  abscess.  Gan- 
grene occasionally  seizes  upon  them,  and  in  a  few  rare  instances 
they  have  given  way  at  one  or  more  points,  followed  by  an 
escape  of  their  contents  into  the  pelvic  cavity,  and  the  develop- 
ment of  fatal  peritonitis. 

No  kind  of  treatment,  either  local  or  general,  is  of  any  avail 
in  this  affection,  the  morbid  changes  of  which  are  entirely  beyond 
the  influence  of  remedies.     The  only  method  that  can  be  adopted 


SACCULATIOX  OF  THE  BLADDER.  67 

is  to  remove  the  exciting  cause,  and  thus  prevent  an}-  further 
increase  of  the  difficulty.  Any  impediment,  therefore,  to  the 
flow  of  urine  sliould  be  sought  for,  and  promptly  attended  to. 
The  water  should  be  passed  at  regular  intervals,  or  drawn  otf 
with  the  catheter,  to  protect  the  bladder  from  overdistention 
and  undue  exertion.  Any  inflammatory  complications  that  may 
manifest  themselves  must  be  met  by  appropriate  remedies. 


CHAPTER   III. 

FUNCTIONAL  DISEASES  OF  THE  BLADDER. 

There  arc  certain  affections  of  the  bladder,  of  whicli,  in  many 
cases,  the  cause  is  nndefinable,  and  in  which  there  is  often  no 
appreciable  lesion.  These  maladies  are  usually  discussed  under 
the  head  of  nervous  diseases,  or  neuroses,  and  include  irritability, 
spasm,  neuralgia,  and  paralysis,  or  conditions  marked  by  in- 
creased, diminished,  or  perverted  sensation,  contractility,  and 
tonicity;  or,  in  other  Avords,  functional  derangement.  In  the 
majority  of  instances,  however,  the  affections  belonging  to  this 
group  can  be  traced  to  inflammation,  mechanical  obstruction,  or 
changes  of  structure  of  some  portion  of  the  urinary  tract,  when 
the  functional  disorders  are  merely  denotive  of  various  patho- 
logical alterations.  Hence,  it  may  not  be  stricth'  correct  to 
treat  of  symptoms  as  specific  diseases;  but  these  conditions  are 
so  common,  so  troublesome,  and  so  harassing  to  the  patient, 
that,  in  accordance  with  the  usual  custom,  I  shall  describe  them 
as  distinct  ati'ections. 

Sect.  I.— IRRITABILITY  OF  THE  BLADDER. 

In  the  absence  of  positive  facts,  the  most  plausible  conclusion, 
perliaps,  is  that  irritability  of  the  bladder  consists  in  an  exalta- 
tion of  the  nervous  sensibility,  or  hyperiesthesia,  of  the  mucous 
membrane,  particularly  at  the  neck  of  the  organ,  whereby  it  is 
rendered  intolerant  of  the  presence  of  the  urine,  which  is  voided 
with  greater  frequency  than  in  the  natural  state.  The  disease 
is  not  peculiar  to  either  sex,  to  any  period  of  life,  or  to  any 
particular  temperament,  habit,  or  occupation.  I  have,  however, 
most  frequently  met  with  it  in  children  and  in  persons  about 
the  age  of  puberty,  and  in  individuals  who  are  naturally  of 
a  nervous,  irritable  disposition,  or  pione  to  attacks  of  gout 
and  rheumatism.  A  very  unpleasant  and  intractable  form  of 
vesical  irritation  occasionally  occurs  in  weak,  scrofulous  subjects. 


IRRITABILITY    OF    THE    BLADDER.  69 

There  is  a  variety  of  this  affection  peculiar  to  young  boj's  and 
girls,  in  which  the  intolerance  of  the  bladder  occurs  chiefly  at 
niffht,  durino;  sleei).  Particular  mention  will  be  made  of  this 
variety  in  the  chapter  on  Incontinence  of  Urine.  The  maladj- 
m;!}^  alfect  the  whole  bladder,  or  only  a  part  of  it ;  in  most  cases 
it  is  limited  to  the  neck  of  the  organ,  and  to  the  prostatic  por- 
tion of  tlie  urethra  ;  regions  remarkable  for  their  sensibility  both 
in  health  and  in  disease. 

"When  the  aftection  is  fully  established,  the  patient  is  obliged 
to  urinate  every  few  minutes,  and  is  hardly  ever  entirely  free 
from  suffering.  The  act,  wliicli  is  generally  more  frequent  in 
the  day  than  at  night,  and  in  the  erect  than  in  the  recumbent 
posture,  is  accompanied  with  tenesmus,  particularly  distressing 
in  obstinate  cases,  more  or  less  straining,  pain  at  the  neck  of  the 
bladder,  and  a  sense  of  scalding  in  the  urethra.  The  stream  of 
water  may  be  natural,  or  variously  altered  in  its  form  and  force. 
Thus,  it  may  be  forked,  twisted,  or  spiral,  strong  and  full,  small 
and  feeble.  In  many  cases,  it  is  ejected  in  jets,  or  voided  in 
drops.  The  fluid  again  may  be  normal  as  to  its  quantity  and 
quality,  or  it  may  deviate  more  or  less  from  the  healthy  standard . 
In  general,  it  is  acid,  high-colored,  and  surcharged  with  mucus. 
In  consequence  of  the  straining,  the  patient  often  suffers  from 
irritation  of  the  rectum,  hemorrhoids,  partial  prolapse  of  the 
mucous  membrane,  and  pruritus  of  the  anus,  or  the  parts  around. 
The  urethra  and  the  prostate  gland  are  generally  unnaturally 
sensitive  to  the  touch,  and  hence  much  difflculty  is  frequentlj- 
experienced  in  attempting  to  introduce  a  catheter  or  bougie, 
which,  from  the  spasm  which  it  excites,  is  sometimes  grasped 
with  extraordinary  flrmness.  A  very  common  accompaniment 
of  this  affection,  especially  in  young  men,  is  a  tendency  to  erec- 
tions and  seminal  emissions.  Indeed,  there  are  few  cases  between 
the  ages  of  twenty  and  thirty,  in  wdiich  this  sjnnptom  is  entirely 
absent.  Neuralgic  pains  of  the  bladder,  the  ]  »enis,  testicles,  and 
spermatic  cord,  are  also  frequently  present,  and  greatly  aggrav^atc 
the  local  distress. 

As  the  disease  wears  on,  the  general  health,  perhaps  originally 
good,  gradually  suffers.  The  digestive  organs  lose  their  tone ; 
the  appetite  is  impaired  ;  the  bowels  are  constipated ;  and  the 
patient  is  harassed  with  flatulence,  colicky  pains,  and  acid  eruc- 
tations.    The  extremities   are  cold,  the  sleep  is   disturbed,  the 


70  FUNCTIOXAL    DISEASES    OF    THE    BLADDER. 

riesb  wastes,  and  the  mind  is  gloomy  and  despondent.  Such  is 
a  faint  picture  of  the  miserable  condition  which  attends  irrita- 
bility of  the  bladder  in  its  confirmed  stages,  and  in  its  more 
aggravated  forms. 

This  disease  is  sometimes  mistaken  for  stone.  Of  this  occur- 
rence I  have  seen  numerous  examples,  the  true  nature  of  whicli 
can  only  be  cleared  up  by  the  use  of  the  sound.  As  the  instru- 
ment advances  through  tlie  curved  portion  of  the  urethra,  the 
canal  will  be  found  to  be  so  extremely  sensitive,  as  to  cause  the 
compressor  muscle  to  contract  spasmodically,  and  prevent  for  a 
moment  its  onward  passage.  When  it  reaches  the  prostatic  por- 
tion, the  patient  will  feel  nauseated  or  faint,  or,  possibly,  have 
a  violent  erection;  and  as  it  approaches  the  neck  of  the  bladder 
the  desire  to  urinate  will  be  uncontrollable.  If  this  part  of  the 
viscus  be  inflamed,  the  contact  of  the  instrument  will  provoke 
intolerable  pain  ;  the  sphincter  closes,  and  in  the  attempts  to 
pass  the  sound,  the  organ  will  be  pushed  before  it,  so  that  it 
may  appear  to  have  entered  it.  If  it  be  left  to  itself,  however, 
it  will  be  partially  pushed  out  by  the  restoration  of  the  neck 
to  its  natural  position;  when  the  spasm  will  soon  disappear  and 
the  instrument  will  enter  by  a  sort  of  suction  process. 

Irritability  of  the  bladder  may  be  arranged  under  dift'erent 
heads,  according  to  the  causes  by  which  it  is  induced,  or  the 
circumstances  under  which  it  is  developed.  1.  Disease  of  the 
urinary  apparatus.  2.  Altered  state  of  the  urine.  3.  Diuretic 
medicines.  4.  Disorder  of  the  genital  organs.  5.  Disease  of  the 
alimentary  canal.  6.  Lesion  of  the  brain  and  spinal  cord.  7. 
General  debility.  8.  Exposure  to  cold  and  heat.  9.  Disease  of 
the  pelvic  viscera. 

1.  Disease  of  the  urinary  apparatus,  no  matter  what  may  be 
its  character  or  situation,  is  a  frequent  cause  of  vesical  irrita- 
bility. Persons  atfected  with  stricture  of  the  urethra,  vascular 
or  papillary  growths  at  the  orifice  of  this  canal,  contraction  of 
the  meatus,  stone,  vesical  catarrh,  hypertrophy  of  the  muscular 
coat  of  the  bladder,  ulceration  of  the  mucous  membrane  of  this 
organ,  enlargement  of  the  prostate  gland,  and  disease  of  the 
ureters  or  kidneys,  are  seldom  free  for  any  length  of  time  from 
this  kind  of  irritability,  which,  in  some  of  the  maladies  here 
mentioned,  is  often  a  source  of  the  most  frightful  suftering. 
The  presence  of  a  tumor,  a  clot  of  blood,  inspissated   mucus, 


IREITABILITY    OF    THE    BLADDER.  71 

fibrinous  exudation,  or  purulent  matter — in  short,  of  any  foreio;n 
or  adventitious  substance — invariably  leads  to  the  same  result. 
A  considerable  degree  of  irritability  of  this  organ  sometimes 
succeeds  to  the  operation  of  lithotomy,  external  injury  of  the 
bladder,  and  perineal  fistule. 

Gonorrhoea  is  a  fruitful  source  of  vesical  irritability.  The 
inflammation  which  characterizes  this  disease  is  often  suddenly 
transferred  from  the  urethra  to  the  neck  of  the  bladder,  sivino' 
rise  to  frequent  micturition,  tenesmus,  and  severe  pain  in  passing 
the  last  drops  of  urine,  which  are  occasionally  mixed  with  blood 
or  pus. 

Irritability  occasionall}^  results  from  congestion  of  the  neck 
of  the  bladder,  the  prostate  gland,  and  the  seminal  vesicles. 
These  organs,  like  other  parts  of  the  body,  are  liable  to  impeded 
circulation',  or  stagnation  of  blood,  causing  simply  turgescence 
of  the  vessels,  and  morbid  sensibility  of  the  mucous  membrane. 
The  condition  is  similar  to  that  of  the  retina  in  certain  forms  of 
amaurosis,  and  most  commonly  occurs  in  robust,  plethoric  sub- 
jects, between  twenty  and  forty  years  of  age.  It  is  characterized 
by  a  feeling  of  fulness  in  the  perineum,  almost  uninterrupted 
micturition,  and  smarting  of  the  neck  of  the  bladder,  with  a 
scalding  sensation  of  the  urethra.  Sometimes  the  patient  is  con- 
scious of  a  strong  throbbing  in  the  parts.  These  sj'mptoms, 
Avhieli  are  always  aggravated  by  exercise,  and  even  by  the  erect 
posture,  are  liable  to  be  renewed  by  the  slightest  exposure  to 
cold,  by  a  lull  meal  and  a  few  glasses  of  wine,  by  drastic  purga- 
tives, and  by  venereal  excesses. 

2.  Irritability  of  the  bladder  is  frequently  induced  by  an 
altered  state  of  the  urine,  which  produces  nearly  the  same  effect 
upon  the  bladder  as  a  foreign  body.  The  fluid  is  generally  more 
or  less  acid,  dark-colored,  and  strongly  disposed  to  become 
ammoniacal.  It  often  deposits  a  copious  sediment  of  mucus,  is 
unusually  scanty,  and  is  speedily  decomposed  after  being  voided. 
This  form  of  irritability  is  most  common  in  elderly  subjects, 
particularly  such  as  are  predisposed  to  gout,  rheumatism,  and 
gravel.  Males  are  more  liable  to  it  than  females.  The  disease 
is  usually  associated  with  disorder  of  the  general  health,  whicli 
is,  doubtless,  the  immediate  cause  of  the  altered  state  of  the 
urine  upon  which  it  depends.  The  most  prominent  symptoms 
are  dyspepsia,  constipation,  capricious  appetite,  sour  eructations, 


72  FUNCTIONAL    DISEASES    OF    THE    BLADDER. 

coklncss  of  tlie  extremities,  dryness  of  the  skin,  soreness  in  the 
lumbar  region,  neuralgic  pains  in  various  parts  of  the  hody,  and 
a  sense  of  burning  in  the  uretiira.  In  protracted  cases,  the 
altered  secretion  is  sometimes  directly  dependent  upon  a  morbid 
condition  of  the  kidney. 

The  presence  of  pus  in  the  urine  must  not  he  overlooked  as  a 
cause  of  this  affection.  The  matter  may  he  derived  from  an 
inflanied  kidney  or  ureter,  or  it  may  he  due  to  the  bursting  of 
a  pelvic  abscess  into  the  hladder,  after  parturition.  Under  these 
circumstances,  tlie  irritability  is  liable  to  be  excessive  and  pro- 
tracted, the  viscus  being  in  a  state  of  continued  tenesmus. 

3.  An  irritahle  state  of  the  hladder  sometimes  results  from 
the  use  of  diuretics.  The  article  most  liahle  to  produce  this 
effect  is  cantharides.  When  taken  internally,  in  an  excessive 
dose,  it  acts  promptly  u[pon  the  urinary  organs,  causing  great 
distress  at  the  neck  of  the  hladder,  with  hurning  of  the  urethra, 
and  the  most  urgent  desire  to  void  the  urine,  which  comes  off 
drop  hy  drop,  usually  tinged  with  hlood,  and  accompanied  hy 
severe  spasm  and  straining.  These  symptoms  are  generally 
attended  hy  the  most  violent  erections.  Exhibited  in  smaller 
quantities,  the  effects  are  more  mild,  hut  hardly  less  persistent, 
and,  in  the  aggregate,  less  distressing.  Xitrate  of  potassa  some- 
times acts  with  extraordinary  power  upon  the  urinary  apparatus. 
I  have  known  an  overdose  produce  effects  upon  the  hladder  very 
similar  to  those  of  cantharides,  and  scarcely  less  severe.  When 
administered  for  a  long  time  as  a  diuretic,  it  seldom  fails  to  irri- 
tate the  neck  of  the  l)ladder,  and  occasion  frequent  micturition. 
Vesical  irritability  is  often  induced  hy  the  use  of  stimulating 
drinks,  fruits,  and  vegetables,  causing  an  excess  of  acid  in  the 
urine,  with  a  morbid  sensibility  of  the  mucous  membrane. 

4.  Venereal  excesses,  whether  in  the  form  of  frequent  coition, 
masturbation,  or  involuntary  losses,  are  prominent  exciting 
causes  of  this  affection;  but  a  more  fruitful  source  of  the  trouble 
is  ungratified  sexual  a])petite,  from  toying  with  females  with- 
out consummating  the  venereal  act.  I  have  met  with  many 
examples  of  this  nature,  particularly  in  young  men;  and  as  tlie 
constant  indulgence  in  this  pernicious  practice  is  liable  to  be 
followed  by  impairment  of  the  virile  powers,  the  sufferers  usually 
consult  the  practitioner  on  account  of  loss  of  confidence  which 
renders  them  temporarily  impotent. 


IE  RIT  ABILITY    OF    THE    BLADDER.  73 

In  boys,  a  marked  degree  of  irritation  about  the  neck  of  the 
Ijladder  is  produced  by  a  long  and  narrow  prepuce,  rendering 
the  affection  liable  to  be  mistaken  for  stone.  The  existence  of 
this  malformation  usually  prevents  the  ready  escape  of  the  urine, 
in  consequence  of  which  the  edges  of  the  foreskin  become 
inflamed  and  sore,  causing  frequent  desire  to  pass  water,  accom- 
panied with  severe  pain  and  even  spasm.  Similar  symptoms  are 
sometimes  due  to  the  accumulation  and  decomposition  of  the 
preputial  smegma,  and  to  congenital  narrowing  of  the  meatus. 

5.  Disorder  of  the  digestive  apparatus  is  capable  of  producing 
this  disease.  The  sympathy  which  exists  between  the  stomacli 
and  urinarj'  bladder  is  familiar  to  every  physiologist  and  patho- 
logist. There  are  few  confirmed  dyspeptics  who  are  entirely 
free  from  this  disease.  The  digestive  powers  of  such  persons  are 
ha1)itually  enfeebled ;  the  stomach  is  sour  and  flatulent ;  the 
bowels  are  costive;  and  the  urine  is  scanty,  high-colored,  and 
surcharged  with  lithic  acid,  or  lithate  of  ammonia. 

An  irritable  state  of  this  organ  is  sometimes  produced  by  the 
presence  of  tseniada,  ascarides,  hardened  feces,  foreign  bodies, 
hemorrhoidal  tumors,  carcinomatous  disease,  ulceration,  or  As- 
sure, of  the  mucous  membrane  of  tJje  rectum,  organic  stricture, 
anal  fistule,  and  prolapse  of  the  bowel.  Pruritus  of  the  anus, 
nates,  and  perineum,  may  also  give  rise  to  it.  The  irritation  in 
these  cases  is  often  excessive,  and  closely  resembles  that  produced 
l>y  stone  in  the  bladder. 

6.  An  irritable  state  of  the  bladder  is  occasionally  dependent 
upon  lesion  of  the  nervous  system.  Many  years  ago  I  attended 
a  gentleman  on  account  of  concussion  of  the  spinal  cord,  pro- 
duced by  a  fall  upon  the  lumljar  region  from  a  wine  cask.  The 
most  prominent  symptoms,  during  the  first  three  days,  were 
disorder  of  the  intellectual  faculties,  and  an  almost  incessant 
inclination  to  void  the  urine,  which  was  remarkably  copious 
and  limpid.  As  the  concussion  subsided,  the  desire  became  less 
frequent,  and  the  fluid  gradually  resumed  its  normal  characters. 
Similar  effects  are  often  noticed  in  injuries  of  the  vertebral  col- 
unm  and  organic  disease  of  the  spinal  cord,  attended  with  partial 
paralysis  of  the  bladder.  The  urine,  in  such  cases,  is  always 
exceedingly  acrid,  high-colored,  offensive,  surcharged  with  glairy 
mucus  and  phosphatic  matter,  and  passed  with  preternatural 
frequency. 


74  FUXCTIOXAL    DISEASES    OF    THE    BLADDER. 

A  considerable  degree  of  morbid  sensibility  of  the  bladder  is 
sometimes  produced  b\'  congestion  of  the  brain,  or  nervous  ex- 
haustion, brought  on  by  mental  fatigue,  or  inordinate  excitement. 
Cases  of  this  description,  which  are  not  bv  any  means  infrequent, 
are  most  conmion  in  elderly  men,  of  sedentary  habits,  and  of  a 
nervous,  excitable  temperament. 

Mere  mental  emotion  will  occasionally  induce  the  affection, 
as  a  violent  paroxysm  of  fear,  grief,  or  anger.  Again,  an  irrita- 
tion seated  in  a  remote  part  of  the  body  has  been  known  to  give 
rise  to  it.  Piuel  saw  an  instance  of  it,  caused  by  disease  of  the 
thyroid  gland. 

Irritability  of  the  bladder  has  sometimes  been  induced  by  the 
habit  of  too  frequent  micturition.  The  urine  is  the  natural 
stimulus  of  the  organ,  and  if  this  is  too  often  withdrawn,  a  cer- 
tain degree  of  intolerance  is  apt  to  be  engendered.  The  organ, 
under  the  influence  of  this  habit,  gradually  diminishes  in  size, 
the  muscuhir  fibres  are  thickened,  and  the  mucous  membrane 
becomes  so  sensitive  as  to  be  unable  to  bear  the  slightest  disten- 
tion. Literary  men  often  suffer  in  this  way,  especially  if  they 
are  dyspeptic,  or  predisposed  to  gout  and  rheumatism. 

There  is  a  form  of  vesical  irritability,  very  common  in  young 
girls,  soon  after  the  age  of  puberty,  which  may  be  appropriately 
included  under  the  present  head,  though,  as  it  respects  its  origin, 
it  is  probably  of  a  mixed  character.  The  affection  is  generally 
associated  with  spinal  irritation,  and  dysmenorrhoea,  or  imperfect 
menstruation.  The  extremities  are  cold,  the  bowels  constipated, 
the  tongue  coated,  the  appetite  impaired,  and  tlie  digestion 
languid  and  difficult.  The  patient,  moreover,  is  flatulent, 
nervous,  and  troubled  with  palpitation  of  the  heart,  the  action 
of  which  is  hurried  by  the  slightest  agitation  and  exertion. 
The  disease  frequently  lasts  for  years,  and  sometimes  during  the 
greater  part  of  life. 

7.  Among  the  causes  of  this  disease  may  be  mentioned  any 
considerable  and  long-continued  debility,  such  as  occurs  from 
immoderate  venery,  spermatorrhoea,  onanism,  hemorrhage,  and 
chronic  diarrhoea.  It  is  occasionally  a  sequel  of  typhus,  typhoid, 
and  other  fevers,  especially  when  the  disease  has  been  very  pro- 
tracted, or  treated  too  energeticalh'. 

8.  Exposure  to  cold,  or  sudden  suppression  of  the  cutaneous 


IRRITABILITY    OF    THE    BLADDER.  75 

perspiration,  is  sometimes  followed  by  this  affection.  This  is 
occasionally  noticed  in  persons  who,  after  having  been  immersed 
for  a  long  time  in  a  hot  atmosphere,  suddenly  go  out  into  the 
open  air  in  a  cold  winter  day.  The  first  effect  of  such  a  transi- 
tion is  a  chilly  state  of  the  surface,  and  an  arrest  of  the  perspi- 
ration, which  are  often  succeeded  in  a  few  moments  by  a  desire 
to  void  the  urine,  so  urgent  as  hardly  to  admit  of  any  delay. 
Exposure  to  the  rays  of  the  hot  sun  is  capable  of  rendering  the 
bladder  temporarily  irritable.  I  have  seen  several  instances  in 
which  the  disease  appeared  to  have  been  thus  induced.  The 
patients  were  all  field  laborers,  and  had  been  engaged  at  hard 
work  in  intensely  hot  weather ;  the  affection  was  characterized 
by  an  incessant  inclination  to  micturate,  by  excessive  scalding 
at  the  neck  of  the  bladder,  and  by  a  sense  of  general  prostration, 
lasting  several  hours  before  it  could  be  relieved. 

9.  Finally,  an  enlarged  ovary,  a  displaced,  gravid,  or  diseased 
uterus,  or  a  morbid  growth  of  the  pelvis,  may  occasion  symp- 
toms of  vesical  irritability.  The  effect  may  be  purely  reflex,  or 
it  may  be  caused  by  pressure  on  the  bladder.  Accoucheurs  are 
well  aware  of  this  occurrence,  of  which  I  have  seen  several  well- 
marked  examples.  The  affection  is  most  common  in  old  and 
middle-aged  females,  although  it  may  take  place  at  an}'  period  of 
life. 

From  what  has  been  said  respecting  the  causes  of  this  affec- 
tion, it  is  not  surprising  that  so  little  should  be  known  of  its 
pathology.  As  the  disease,  in  its  idiopathic  form,  never  of  itself 
proves  fatal,  opportunities  of  ascertaining,  by  dissection,  the 
exact  condition  of  the  parts,  are  exceedingly  infrequent ;  and  in 
the  few  cases  in  which  they  have  been  afforded  no  satisfactory 
results  have  been  observed.  The  most  plausible  theory  is  that 
the  complaint  consists  in  an  exalation  of  the  nervous  sensibility 
of  the  mucous  membrane,  similar  to  what  is  occasionally  witnessed 
in  the  retina,  the  fauces,  urethra,  and  other  mucous  canals. 
What  strengthens  this  opinion  is  the  fact  that  it  is  frequently 
connected  with  a  weak,  scrofulous  state  of  the  constitution;  and 
that,  Avhen  this  is  the  case,  it  generally  resists  every  mode  of 
treatment  that  has  yet  been  devised  for  its  relief ;  affording  thus 
an  analogy,  and  that  a  very  striking  one,  to  certain  forms  of 
strumous   ophthalmia,   alike    distressing    to    the    patient   and 


7G  FUNCTIOXAL    DISEASES    OF    THE    BLADDER. 

troul)]esome  to  the  surgeon.  The  l)la(kler,  in  the  more  cou- 
ftniK'd  stages  of  the  afteetion,  is  much  contracted,  hut  its  coats, 
instead  of  being  thickened,  are  general!}'  preternaturallj  thin, 
and  remarkable  for  their  pallor. 

When  the  complaint  de[)ends  upon  local  causes,  as  stone  in  the 
bladder,  stricture  of  the  urethra,  or  enlargement  of  the  prostate 
gland,  the  anatomical  changes  are  more  distinct,  and  aftbrd  a 
more  satisfactory  solution  of  the  real  nature  of  the  case.  Under 
such  circumstances,  there  are  always,  or  nearly  always,  evidences 
of  inflammation  or  congestion  of  the  lining  membrane  and  hyper- 
trophy of  the  muscular  fibres,  with  alteration  of  the  secretions, 
and,  in  some  instances,  slight  deposits  of  lymph. ^ 

Very  frequently,  as  was  previously  remarked,  the  irritahility 
is  purely  sympathetic,  depending  upon  lesion  of  some  neighbor- 
ing organ,  as  the  kidney,  seminal  vesicle,  penis,  anus,  uterus, 
stomach,  or  bowel.  I  have  already  alluded  to  an  instance  in 
which  it  seemed  to  have  been  produced  by  a  diseased  condition 
of  the  thyroid  gland  ;  and  the  fact  that  it  is  occasionally  excited 
by  congestion  or  organic  lesion  of  the  brain,  independently  of 
any  appreciable  structural  change  of  the  bladder,  is  familiar  to 
every  pathologist. 

The  prognosis  of  this  affection  is  influenced  by  so  many  con- 
tingent and  concomitant  circumstances,  that  any  remarks  that 
may  l)e  made  respecting  it  must  of  necessity  be  vague  and 
indefinite.  This  will  not  appear  strange,  when  we  take  into 
consideration  the  great  number  and  variety  of  causes  by  which 
it  is  induced  and  maintained.  The  idiopathic  form  of  the  com- 
plaint, although  frequently  very  obstinate,  generally,  after  a 
time,  yields  to  a  Avell-directed  course  of  treatment.  When  the 
disease  occurs  in  weak,  scrofulous  subjects,  it  is  always  remark- 
ably intractable,  frequentl}'^  lasting  for  years,  or  ending,  perhaps, 
onl}'  with  life.  The  irritation  of  the  bladder  of  young  children, 
attended  with  nocturnal  incontinence  of  urine,  sometimes  dis- 

'  111  a  young-  man,  who  -vyas  affected  with  urinaiy  calculus,  the  membranous 
and  prostatic  urethra  and  ueck  of  the  bladder  were  extremely  sensitive  upon 
instrumental  contact,  and  frequent  micturition  was  a  prominent  symptom.  On 
dissection,  by  the  editor,  immediately  after  death  from  litliotomy,  these  parts 
were  seen  to  be  llie  seat  of  linear  injection,  the  enlarged  bloodvessels  corre- 
sponding with  ilic  natural  folds  of  the  urethra. 


IRRITABILITY    OF    THE    BLADDER.  77 

appears  spontaneously  towards  the  ap|)roaeli  of  pul)erty,  while 
at  other  times  it  is  exceedingly  rebellious,  and  successfully 
resists  the  most  judiciously  devised  means  of  the  physician  to 
overcome  it.  Hj'sterical  irritability,  seldom  continues  long, 
although  it  is  not  always  readily  amenal)le  to  treatment. 

When  dependent  upon  local  causes,  of  a  curable  nature, 
prompt  relief  maj-  generally  be  obtained.  All,  in  fact,  that  is 
necessary,  in  such  cases,  is  to  remove  the  source  of  the  irritation, 
and  the  disease  will  subside  of  its  own  accord.  Under  opposite 
circumstances,  however,  the  complaint  is  commonly  irremedi- 
al;le,  however  judicious  our  efforts  to  coml>at  it.  Thus,  nothing 
can  be  done,  with  any  reasonable  hope  of  success,  for  a  case  of 
irritability  of  the  bladder,  caused  by  carcinoma  of  the  rectum, 
an  enlarged  ovary,  or  a  tubercular  kidne}' ;  and  so  of  many  other 
forms  of  the  disorder. 

In  entering  upon  the  treatment  of  this  complaint,  so  Protean 
in  its  character,  a  strict  inquiry  should,  in  every  instance,  be 
instituted  into  its  origin,  which,  as  has  been  already  seen,  may 
be  either  sympathetic,  nervous,  congestive,  or  inflammatory ; 
and  the  practice  j-egulated  accordingly  ;  otherwise  the  physician 
will  oidy  be  likely  to  harass  his  patient,  and  employ  means  which 
can  lead  to  no  beneficial  result.  Indeed,  it  may  be  confidently 
affirmed  that  there  is  no  class  of  diseases  which  demand  a  more 
thorough  investigation  to  enable  him  to  form  a  correct  judgment 
upon  the  parts  primarily  affected  than  this.  The  truth  of  this 
remark  is  fully  borne  out  by  the  long  catalogue  of  causes  under 
the  influence  of  which  tliis  disorder  is  developed,  and  which  no 
one  can  read  without  being  impressed  with  the  importance  of  a 
most  profound  knowledge  of  the  physiology  and  pathology  of 
the  urinary  apparatus. 

The  exciting  cause  of  this  complaint  having  been  ascertained, 
the  first  thing  to  be  attempted  is,  if  possible,  to  remove  it.  All 
venereal  excesses  or  irregularities  must  be  abandoned.  Of  the 
internal  remedies  which  may  be  advantageously  employed  in 
most  of  the  varieties  of  the  affection,  I  have  found  that  bella- 
donna, in  the  form  of  the  sixth  of  a  grain  of  the  extract,  or  five 
drops  of  the  juice,  repeated  every  six  or  eight  hours,  is  the  most 
useful.  Small  doses  of  balsam  of  copaiba  are  particularly 
applicable  to  irritability  dependent  upon  the  extension  of  gonor- 


78 


FUNCTIONAL    DISEASES    OF    THE    BLADDER, 


Fisr.  10. 


rho^al  inflanimation,  vesical  catarrh,  and  organic  disease  of  the 
kidney.  In  young  children  and  hysterical  girls,  I  have  derived 
great  benetit  from  the  tincture  of  cantharides, 
combined,  when  a  tonic  is  at  the  same  time 
Indicated,  with  the  tincture  of  the  chloride  of 
iron.  AVhen  the  irritability  arises  from  sexual 
irregularities,  I  know  of  no  remedies  so  well 
calculated  to  be  productive  of  good  eft'ects,  as 
the  bromide  of  potassium,  or  ammonium,  in 
doses  of  thirty  grains,  along  with  fifteen  grains 
of  chloral  hydrate,  for  an  adult,  thrice  in  the 
twentj-'four  hours. 

Of  the  local  measures  to  allay  tlie  disordered 
sensibility  of  the  afi'ected  parts,  b}-  far  the  most 
reliable  is  the  gentle  introduction  of  a  conical 
steel  sound  of  moderate  size,  which  should,  at 
first,  be  instantaneously  withdrawn.  As  the 
sensitiveness  decreases,  it  is  retained  for  three 
or  four  minutes  ;  and  a  larger  instrument  should 
be  substituted,  until  tlie  hyperK'sthesia  is  com- 
pletel}'  obtunded.  The  opera'tion  may  be  re- 
peated, as  a  rule,  every  fortj'-eight  hours. 
Should  the  introduction  of  the  sound  aggra- 
vate the  local  distress,  its  use  must  be  preceded 
by  sedative  and  astringent  injections,  such  as 
two  grains  of  nitrate  of  silver  and  five  grains 
of  opium  to  the  ounce  of  water,  or  half  a 
drachm  of  Goulard's  extract  and  eight  grains 

Oof  the  watery  extract  of  opium  to  four  ounces 
'  of  water.     The  fluid  is  conveyed  to  the  seat  of 

Catheter  Syringe.        tlic   discasc  by  mcaus  of  the   catheter   s^a'inge 
represented   in   fig.   10,  exemption   from   pain 
being    secured  by  passing  the  nozzle  onlj'  through  the  opening 
in  the  triangular  ligament. 


Sect.  II.— SPASM  OF  THE  BLADDER. 


The  characteristic  symptom  of  spasm  of  the  bladder  is  sudden, 
uncontrollable,  excessively  painful,  and  remitting  contractions 
of  the  organ,  during  which  the   urine   may  be  discharged  by 


SPASM    OF    THE    BLADDER.  79 

drops,  or  in  an  irregular,  jerking  stream,  or,  as  more  frequently 
happens,  tliere  is  retention  of  that  fluid  until  the  attack  passes 
oft".  The  suttering  is  exquisite,  and  is  reflected  along  the  urethra 
to  the  head  of  the  penis  ;  while  the  desire  to  empty  the  bladder 
is  constant  and  attended  with  violent  tenesmus,  often  terminat- 
ing in  rupture  of  the  capillary  vessels  of  the  neck  of  the  viscus, 
and,  as  a  re'feult,  in  the  emission  of  a  few  drops  of  blood  at- the 
completion  of  each  act  of  micturition. 

The  true  cause  of  this  aftection  is  not  always  appreciable.  It 
may  generally,  however,  be  traced  to  cold,  the  suppression  of 
the  cutaneous  perspiration,  hysteria,  acid  urine,  pyelitis,  gravel, 
the  presence  of  a  calculus,  clots  of  blood,  or  a  tumor  in  the  blad- 
der, vesical  catarrh,  or  ulceration,  organic  lesions  of  the  prostate, 
stricture  of  the  urethra,  the  extension  of  gonorrhceal  inflamma- 
tion, pelvic  hematocele,  abscesses  in  the  neighborhood  of  the 
bladder,  metritis  or  perimetritis,  carcinoma  of  the  rectum, 
ascarides,  hemorrhoidal  tumors,  fissure  of  the  anus,  operations 
on  the  rectum,  and  the  effects  of  turpentine  and  cantharides. 

When  the  trouble  has  existed  for  some  time,  or  proved  rebel- 
lious to  ordinary  measures,  it  very  commonly  results  in  con- 
centric hypertrophy  of  the  bladder,  the  organ  being  incapable  of 
retaining  more  than  a  few  drops  of  urine  at  a  time ;  and  the 
patient  becomes  emaciated  and  exhausted  from  the  suffering 
induced  by  the  frequent  recurrence  of  the  attacks.  Under  these 
circumstances,  the  spasmodic  affection  may  be  mistaken  for 
stone,  and  cystotomy  has  been  performed  in  several  instances 
Avith  the  happiest  effect,  although  no  calculus  was  found. 

The  treatment  of  spasm  of  the  vesical  sphincter  and  muscles 
of  the  curved  urethra,  npon  which  the  affection  essentially 
depends,  must  be  conducted,  in  the  first  place,  upon  the  recogni- 
tion and  removal  of  its  exciting  cause.  The  attack  itself,  from 
whatever  lesion  it  may  arise,  is  allayed  by  the  warm  bath,  hot 
fomentations,  and  the  inhalation  of  chloroform,  aided  by  the 
free  use  of  camphor  and  opium,  either  by  the  mouth  or  rectum, 
or  by  hypodermic  injections  of  morphia.  When  the  s^-mptoms 
of  retention  are  urgent,  recourse  is  had  to  the  soft  catheter, 
which  often  overcomes  the  spasm  in  an  instant,  long  before  it 
has  reached  the  bladder.  When  the  introduction  is  difficult, 
tlie  instrument  should  be  gently  pressed  against  the  obstruction 


.80  FUXCTIOXAL    DISEASES    OF    THE    BLADDER. 

and  then  suddenly  withdrawn  ;  a  manoeuvre  whicli  rarely  fails 
to  he  followed  hy  complete  relief. 

In  unuBually  ohstinate  cases,  attended  witli  hreaking  down  of 
the  general  healtli,  the  hest  chance  of  obtaining  any  permanent 
benefit  is  afforded  hy  putting  the  Idadder  at  rest,  hy  an  incision 
carried  through  the  memhranes  and  prostatic  portions  of  the 
urethra  and  the  neck  of  the  organ.  In  this  way,  paf'ticularly  if 
the  wound  he  kept  0[»en  for  several  wrecks,  au  outlet  is  formed  for 
the  constant  escape  of  the  urine,  without  any  exertion  on  the 
part  of  the  muscular  fibres  involved  in  the  disease.  The  bladder 
may  be  reached  by  lateral  incisions,  as  was  originally  suggested 
by  Mr.  Bickersteth  ;'  or  through  the  median  line,  w'ith  extensive 
division  of  its  neck,  as  has  been  successfully  practised  by  M. 
Parona.^  Subcutaneous  incision  of  the  neck  of  the  bladder  has 
also  been  resorted  to  in  this  affection,  but  without  any  marked 
result. 

In  females,  in  whom  this  symptom  is  by  no  means  uncommon, 
I  have  in  four  instances  succeeded  in  effecting  permanent  relief 
hy  rapid  dilatati(^n  of  the  urethra  and  neck  of  the  bladder, 
by  means  of  the  finger  and  the  instrument  represented  in  the 
chapter  on  Stone  in  the  Bladder  of  the  Female.  In  this  way,  the 
parts  are  put  thoroughly  at  rest,  and  recovery  is  rapid.  In  two 
of  my  cases  there  was  incontinence  of  urine,  respectively,  for 
three  and  five  days.  Equally  gratifying  results  have  been 
obtained  by  Dr.  nowe,^  and  by"  Mr.  T.  "Pridgin  Teale,"  Mr. 
Heath,*  Mr.  Hewetson,"  and  Dr.  Edis,'  of  England. 

Sect  III.— NEURALGIA  OF  THE  BLADDER. 

As  the  name  imports,  neuralgia  of  the  bladder  is  a  nervous 
affection,  characterized  by  severe  suffering,  which  is  generally 
referred  to  tlie  neck  of  the  organ.  It  presents  itself  in  two 
varieties  of  form,  in  one,  and  the  more  common,  of  which,  the 
suffering  is  more  or  less  steady  and  persistent,  often  remitting, 
but  seldom  intermitting;    whik'  in    the  other,  it  is  distinctly 

I  Liverpool  Medical  and  Siirgieal  Reports,  vol.  i.,  1867,  p.  104. 

^  Hrit.  and  For.  .Mel.-Oliir.  Review,  Januiry.  187-1,  p.  2i-i. 

^  Medical  Record,  vol.  x.  p.  550. 

^  London  Lancet,  vol.  ii.,  1875,  p.  7G1,  and  vol.  i.,  1870.  p.  85. 

5  Il)id.,  vol.  ii.,  1875,  p.  8-.S.  e  ibid.,  vol.  ii.,  1875,  p.  796. 

'   Ibid.,  vol.  ii.,  1S75,  p.  'j  <J. 


NEURALGIA  OF  THE  BLADDER.  81 

paroxysmal,  occurring  tlail}',  or  evcrj'  other  day,  about  the  same 
period.  During  my  residence  in  Kentucky  I  witnessed  many 
examples  of  it,  six  of  which  were  detailed  in  a  former  edition  of 
this  work. 

In  the  early  stage  of  this  disease,  the  symptoms  are  frequently 
vague  and  ill-defined.  At  first,  there  is  merel}^  a  sense  of  uneasi- 
ness in  the  perineal  region,  accompanied  with  a  sharp,  darting, 
or  tingling  pain,  recurring  only  at  long  intervals.  Sometimes, 
in  addition  to  the  shooting  pain,  there  is  an  unpleasant  aching, 
with  a  feeling  of  numbness.  In  this  manner  three  or  four  days 
may  elapse  before  the  disease  attracts  any  particular  attention. 
By  degrees  the  attacks  become  more  frequent,  as  well  as  more 
severe,  and  assume  a  decidedly  periodical  character,  returning 
about  the  same  hour  ever}^  day,  generally  early  in  the  evening 
or  tOAvards  morning.  The  paroxysms  vary  in  their  duration 
from  two  to  six  hours,  and,  while  they  continue,  the  sufiering  is 
often  of  the  most  racking  and  agonizing  nature.  The  pain, 
which  is  commonly  of  a  sharp,  stabbing,  darting  description,  is 
distinctly  referred  to  the  neck  or  inferior  part  of  the  l)ladder. 
and  bears  a  very  exact  resemblance  to  that  produced  l)y  a  fit  of 
the  stone.  In  most  cases  it  extends  to  the  neighboring  organs, 
as  the  rectum  and  anus,  the  urethra,  and  the  inside  of  the  thighs. 
In  the  female  it  is  occasionally  reflected  upon  the  uterus,  and  in 
the  male  along  the  course  of  the  spermatic  cords.  In  both  sexes 
it  is  generally  very  severe  in  the  sacral  and  lumbar  regions. 
Coincident  with  this  is  a  sensation  of  heat  and  burning  in  the 
urethra,  with  a  frequent  desire  to  make  water,  which  is  always 
attended  with  difficulty.  The  burning  or  smarting  is  particularly 
distressing  at  the  extremity  of  the  penis,  from  which  it  frequently 
extends  to  other  parts,  as  the  pubes,  groin,  anus,  or  sacrum.  The 
urine  is  thrown  out  in  jets,  or  the  stream  is  suddenly  arrested. 
and  the  smaller  the  quantity  in  the  bladder  the  greater  is  the 
suffering  in  voiding  it. 

The  paroxysm  generally  goes  oft'  gradually,  leaving  no  other 
inconvenience  than  a  sense  of  soreness  or  aching  in  the  neck  of 
the  bladder,  perineum,  and  posterior  part  of  the  urethra.  During 
the  intermissions  the  urine  is  voided  without  difticulty,  and  the 
patient  feels  comparatively  comfortable,  almost  as  well,  indeed, 
as  if  he  had  not  suftered  any  pain.  When  the  attacks  assume 
the  quotidian  type,  thej^  usually  occur,  as  was  before  intimated, 
6 


82  FUNCTIOXAL    DISEASES    OF    THE    BLADDER. 

ill  the  evoniiiiii;,  during  tlie  niglit,  or  early  in  the  morning. 
Occasionally  they  make  their  appearance  soon  after  eating,  and 
in  a  few  instances  they  have  been  knoAvn  to  recur  twice  in  the 
twenty-four  hours;  tlius  leaving  the  poor  patient  scarcely  a 
moment  free  from  distress. 

Fever  rarely  accompanies  this  afi'ection,  hoAvever  obstinate  or 
protracted.  The  appetite  is  variable  and  capricious,  the  stomach 
is  teased  with  flatulence,  digestion  is  bad,  and  the  patient  feels 
uncomfortable  after  eating.  The  bowels  are  disposed  to  be  torpid, 
and  require  to  be  regulated  by  medicine.  The  sleep  is  interrupted 
and  unrefreshing;  the  pulse,  which  at  first  is  not  perceptibly 
altered,  becomes  quick  and  irritable ;  the  feet  and  hands  are 
habitually  cold  ;  the  general  health  gradually  declines  ;  and  the 
countenance  wears  an  anxious,  haggard  look.  In  inveterate 
cases,  there  is  a  discharge  of  thin  gleety^matter  from  the  bladder, 
with  great  soreness  in  the  perineum  and  hypogastric  region. 
Another  symptom  which  is  occasionally  present  is  a  sense  of 
coldness  in  these  parts,  which  frequently  extends  to  the  groin 
and  inner  parts  of  the  thighs,  and  is  almost  constantly  accom- 
panied witli  some  degree  of  numbness.  The  urine  is  almost 
always  natural,  both  in  regard  to  quality  and  quantity,  except 
in  gouty  and  rheumatic  subjects,  in  whom  it  is  generally'  acid, 
scanty,  and  charged  with  lithates. 

The  diagnostic  signs  of  this  disease  are  not  always  very  dis- 
tinct. The  attacks,  especially  when  very  severe,  bear  the  closest 
resemblance  to  the  paroxysms  produced  by  a  calculus,  and  they 
are  frequently  associated  with,  if  not  dependent  upon,  other 
affections.  Hence,  in  doubtful  cases,  sounding  of  the  bladder  is 
advisable,  and  should  never  be  omitted.  On  the  whole,  the  most 
important  signs,  perhaps,  are  the  paroxysmal  character  of  the 
<lisease,  the  sharp  and  darting  pains,  the  uncomfortable  itching 
and  scalding  in  making  water,  the  attempts  at  which  are  very 
frequent,  urgent,  and  difiicult,  and  the  numbness  of  the  perineum, 
scrotum,  groins,  and  thio-hs. 

Of  the  causes  of  vesical  neuralgia  very  little  is  known.  In 
general,  indeed,  they  are  wholly  inappreciable.  It  is  often  asso- 
ciated with  disease  of  the  neighboring  organs,  but  how  far  it  is 
influenced  by,  or  dependent  upon  it,  it  is  impossible,  in  the 
present  state  of  our  knowledge,  to  determine.  In  some  cases  it 
is  complicated  with  obstinate  amenorrhoea  ;  in  others  it  has  lieen 


XEURALGIA  OF  THE  BLADDER.  83 

known  to  supervene  upon  parturition,  to  continue  for  several 
months,  and  then  totally  disappear.  It  is  observed,  for  the  most 
part,  in  persons  of  a  nervous  temperament,  and  in  those  who  are 
subject  to  the  same  malady  in  other  regions  of  the  bod}-.  Vene- 
real indulgences,  masturbation,  stricture  of  the  urethra,  stone 
in  the  bladder,  organic  disease  of  the  uterus,  and  hemorrhoidal 
ati'ections,  are  all  capable  of  exciting  it.  In  the  case  of  a 
married  woman,  twenty-nine  years  of  age,  under  my  care  in 
1846,  it  was  due  to  a  tumor  of  the  left  nympha,  the  excision 
of  which  was  followed  by  a  rapid  and  permanent  recovery. 
Habitual  constipation  of  the  bowels,  d}- spepsia,  mental  emotions, 
and  a  depraved  condition  of  the  urinary  secretion,  are  also  cir- 
cumstances which  favor  its  production.  What  influence,  if  an^-, 
miasm  exerts  upon  its  development  is  not  ascertained.  Judging 
from  my  own  experience,  however,  it  is  witliout  doubt  a  very 
frequent  cause.  An  elderly  gentleman  whom  I  attended  several 
j-ears  ago,  was  subject  to  neuralgic  attacks  of  tlie  bladder  and 
right  knee,  wdiich  generally  lasted  eight  or  ten  days  at  a  time, 
then  disap[)eared  and  recurred  about  once  every  three  months. 
In  early  life  he  had  been  severely  affected  wdth  rheumatism,  and 
a  short  time  before  the  vesical  neuralgia  came  on  he  had  laljored 
under  intermittent  fever,  which  left  him  with  an  enlarged  and 
indurated  state  of  the  spleen. 

Xeuralgia  of  the  bladder  is  not  confined  to  an}*  particular 
period  of  life,  although  the  old  and  middle-aged  are  without 
doubt  most  subject  to  it;  and  I  have  met  with  it  as  early  as  two 
years  of  age.  Nor  is  it  [leculiar  to  the  male  sex.  Women  not 
infrequently  suffer  from  it,  but  in  what  proportion  is  a  point 
concerning  which  we  are  still  ignorant. 

Vesical  neuralgia,  although  an  exceedingly  painful  and  dis- 
tressing disease,  seldom  terminates  fatally.  Of  this  occurrence 
I  have  onl}'  met  with  two  examples,  one  in  a  man  twenty-eight 
years  of  age,  the  other  in  a  child  two  years  old  ;  death  in  both 
instances  having  been  due  to  exhaustion  induced  b}"  protracted 
suffering.  In  many  cases,  perhaps  the  majority  of  tliem,  it  is 
remarkably  obstinate,  and  persists  for  weeks  or  even  months,  in 
spite  of  the  best-directed  treatment ;  on  the  other  hand,  instances 
occasionally  occur  which  disappear  almost  as  suddenly  as  they 
come  on.  This  is  especially  the  case  when  the  disease  has  a 
miasmatic  origin,  or  when  it  sujiervenes  upon  intermittent  fever. 


84  FUXCTIOXAL    DISEASES    OF    THE    BLADDER. 

Occasionally  it  continues  with  Init  little  intermission  for  several 
years,  thus  undermining  the  general  health,  and  laying  the  foun- 
dation of  serious  and  irreparable  mischief. 

It  is  obvious,  from  what  has  been  already  stated,  that  the 
treatment  of  this  aifection  must  be  regulated  by  the  causes  by 
which  it  is  induced  ;  but  it  must  not  always  be  expected  that 
the  disease  will  rapidly  disappear  upon  the  removal  of  the  excit- 
ing; cause.  There  are  cases  in  which  it  is  inclined  to  lino-er, 
with  little  or  no  mitigation,  for  an  indelinite  period,  despite  the 
faithful  employment  of  remedies.  When  the  aifection  is  at- 
tended with  inflammatory  symptoms,  especially  when  there  is 
tenderness  in  the  perineum,  the  course  of  the  urethra,  the  sac- 
rum, or  the  loins,  prompt  and  eflicient  bloodletting  is  the  remedy 
upon  which,  in  the  commencement,  great  reliance  may  be  placed. 
Mercurial  purgatives  are  decidedl}-  useful  in  that  form  of  neu- 
ralgia dependent  upon  a  miasmatic  origin,  derangement  of  the 
digestive  apparatus,  or  disordered  menstrual  action :  when  the 
disease  is  of  "miasmatic  origin,  quinine  should  be  administered 
in  doses  of  ten  grains  every  eight  hours,  until  thirty  grains 
have  been  taken.  It  should  then  be  discontinued  until  the  next 
day,  when  it  should  be  resumed,  and  persevered  in  until  the 
same  quantity  is  taken.  When  the  violence  of  the  malady  has 
been  thus  moderated  or  subdued,  its  action  should  be  maintained 
by  smaller  doses,  in  combination  with  antineuralgic  remedies. 
An  excellent  formula  which  I  have  been  in  the  habit  of  using; 
for  many  years  is,  two  grains  of  quinine,  half  a  grain  of  extract 
of  aconite,  the  twentieth  of  a  grain  of  morphia,  the  thirtieth  of 
a  grain  of  stryclinia,  the  fifteenth  of  a  grain  of  arsenious  acid, 
and  the  fiftieth  of  a  grain  of  atropia,  given  in  pill  form  three  or 
four  times  in  the  twenty-four  hours.  In  persons  of  a  gouty, 
rheumatic  habit,  colchicum  is  the  proper  remed}-. 

To  moderate  the  violence  of  the  paroxysm,  large  doses  of  mor- 
phia, either  alone  or  associated  with  tartar  emetic  and  tincture 
of  aconite,  according  to  the  state  of  the  vascular  system,  are  in- 
dispensable. When  the  pain  is  very  violent,  the  anodyne  should 
be  thrown  under  the  skin,  and  the  patient  be  brought  under  the 
influence  of  chloroform.  An  emetic,  at  the  approach  of  the 
attack,  will  sometimes  cut  it  short,  or  abridge  it,  particularly 
when  it  is  associated,  as  it  often  is  in  malarious  districts,  with 
gastric  and  biliary  disorder.     Much  benefit  will  also  accrue  from 


PARALYSIS  AXD  ATOXY  OF  THE  BLADDER.      85 

the  warm  bath, the  application  of  steam,  or  fomentations  of  hops 
and  laudanum  to  the  affected  part.  In  the  more  aggravated 
forms  of  the  malady,  counter-irritation,  in  the  form  of  the  actual 
cautery  and  the  caustic  issue,  over  the  perineum,  the  liypogas- 
tr'ium,the  sacrum,  or  inner  part  of  the  thighs,  is  worthy  of  trial. 
Finally,  the  gentle  introduction  of  the  conical  steel  sound  is 
sometimes  followed  by  prompt  and  decisive  benefit ;  but  should 
it  aggravate  the  local  distress,  its  use  must  be  abandoned.  The 
strictest  attention  should  be  paid  to  the  diet ;  everything  tend- 
ing to  disorder  the  digestive  organs,  and  induce  acidit}'  and 
flatulence,  being  avoided.  Dyspepsia  should  be  relieved  by 
tonics,  and  large  doses  of  subnitrate  of  bismuth,  rubbed  up  with 
bicarbonate  of  soda,  pulverized  gum  Arabic,  ginger,  and  cam- 
phor. Flannel  should  be  worn  next  the  skin  ;  exposure  of  all 
kinds  should  be  sedulously  guarded  against ;  and  sexual  inter- 
course should  be  prohibited,  except  at  regular  intervals. 

Sect.  IV.— PARALYSIS  AND  ATONY  OF  THE  BLADDER. 

When  the  bladder  is  deprived,  wholly  or  in  part,  of  the 
power  of  expelling  its  contents,  it  is  said  to  be  in  a  state  of 
paralysis.  It  is  important  to  know  that  the  affection  may  be 
of  eccentric  or  centric  origin,  or,  in  other  words,  that  it  may  be 
dependent  u]wn  causes  inherent  in  the  organ  itself,  or  upon  a 
diseased  condition  of  the  brain  or  spinal  cord.  Another  dis- 
tinction, lono;  ago  recognized  bv  Zubert  and  other  German 
authors,  is  into  paralysis  of  the  neck  of  the  organ,  and 
paralysis  of  its  body.  This  arrangement  is  of  no  little  prac- 
tical importance,  inasmuch  as  the  first  variety  of  the  affection 
is  generally  attended  with  incontinence,  and  the  other  with 
retention  of  urine. 

1.  Atony  or  Parali/sis  of  the  Bladder  from  local  causes. — Closely 
allied  to  true  paralysis,  or  paralysis  from  disease,  or  injury  of 
the  cerebro-spinal  axis,  is  atony  of  the  viscus.  By  many  modern 
writers  this  condition  is  considered  to  arise  from  a  loss  of  tone 
of  the  muscular  walls,  from  overdistention,  and,  as  it  is  of  local 
origin,  they  endeavor,  but  not  very  satisfactorily,  to  separate 
the  two  afiections,  not  seeming  to  recoo-nize  the  fact  that  palsy 
may  be  due  to  eccentric  as  well  as  centric  lesions  of  the  nervous 
system.     Xow  it  is  not  true  that  atony  arises  in  all  cases  merely 


86  FUXCTIOXAL    DISEASES    OF    THE    BLADDER. 

from  overrlistention  of  the  muscles  of  the  bladder.  The  essen- 
tial difficulty  resides  not  in  the  muscles,  but  in  the  nerves  of  the 
or^an,  which  are  stretched  and  compressed  by  the  accumulation 
of  urine,  whereby  they  are  prevented  from  transmitting  motor 
force  to  the  muscles  which  tlic}'  supply.  That  the  stretching 
of  nerves  is  followed  by  impairment  of  their  functions,  and 
diminished  or  inhibited  muscular  tension  or  tonicity,  is  at- 
tested by  what  is  seen  in  dislocations  of  the  larger  joints  and 
attempts  at  their  reduction.  In  these  cases  there  is  decided 
paralysis  of  motion,  and  partial  antesthesia.  An  example  of 
temporar}'  palsy  from  compression  of  the  trunk  of  a  nerve,  with 
which  every  practitioner  of  any  experience  is  familiar,  is  the 
loss  of  power  in  the  muscles  of  the  hand  and  forearm  from  the 
subject  having  slept  for  several  hours  with  his  head  resting  upon 
his  arm.  These  are  instances  of  muscular  paresis  from  causes 
altogether  independent  of  centric  lesions :  and  the  same  is  true 
of  the  bladder.  Atony  may,  however,  depend  upon  causes 
w^hich  have  no  necessary  or  apparent  connection  with  afltections 
of  the  nervous  system.  To  place  the  entire  subject  in  a  more 
intelligible  light,  Ave  Avill  consider  each  variety  of  atony  sepa- 
ratelj'. 

a.  There  is  a  form  of  atony  of  the  bladder  to  which  the  term 
senile  may  be  appropriately  applied,  as  it  is  almost  peculiar  to 
old  age.  As  the  body  loses  its  elastieit}',  the  cornea  grows  dim, 
and  the  power  of  locomotion  diminishes,  the  bladder,  partici- 
pating in  the  general  decay,  becomes  less  capable  of  expelling 
its  contents.  There  is  no  mechanical  obstruction  to  the  flow  of 
urine,  but  simply  a  want  of  power  in  the  muscular  iibres  of  the 
bladder,  in  consequence  of  which  it  contracts  feebly  and  imper- 
fectl}-.  The  paralysis  is  seldom  complete,  and  usually  comes  on 
in  a  slow,  stealthy  manner,  having  already,  in  most  cases,  made 
considerable  progress  before  there  is  any  suspicion  of  its  real 
character.  One  of  the  first  symptoms  which  attracts  attention 
is  a  slight  difficulty  in  starting  the  urine ;  the  patient  is  con- 
scious that  he  is  obliged  to  make  a  greater  effort ;  and  a  longer 
period  is  required  to  complete  the  evacuation.  At  the  close  of 
the  discharge,  the  water  comes  away  in  drops,  and  a  portion 
often  remains  in  the  urethra,  from  which  it  issues  at  the  end  of 
micturition,  thus  soiling  the  linen  and  causing  more  or  less  dis- 
comfort.    The  power  of  expelling  the  urine  is  not  usually  lost  ; 


PARALYSIS    AND    ATOXY    OF    THE    BLADDEl^.  »( 

Itiit  tlie  bladder  is  never,  at  any  time,  entirely  emptied,  a  small 
qnantity  of  urine  being  retained  in  the  fundus,  where  it  becomes 
a  source  of  irritation.  As  the  disease  advances,  the  muscular 
contractility  is  still  further  impaired  ;.  and  the  jvater,  instead  of 
being  ejected  in  a  full  stream,  falls  between  the  patient's  legs, 
being  passed  without  any  projectile  force. 

This  variety  of  atony  is  altogether  independent  of  nervous 
troubles.  The  condition  is  a  physiological  one,  and  is  one  of 
the  infirmities  of  advancing  years,  being  associated  with  a 
general  loss  of  tone  of  the  muscular  and  vascular  tissues  of  the 
body.  If  the  bladders  of  old  men  be  examined  after  death,  it 
will  be  seen  that  the  venous  plexuses  are  greatly  dilated,  and 
that  the  organ  is  surrounded  l)y  an  abundance  of  free  fat. 
]VIinute  inspection,  moreover,  will  demonstrate  coincident  fatty 
degeneration  of  the  muscular  walls  of  the  viscus  ;  and  it  is  this 
change  which  gives  rise  to  the  vesical  debility  of  old  persons. 
The  dysuria  and  final  retention  of  urine,  if  the  calls  of  nature 
l»e  not  promptly  obeyed,  depend  upon  fatty  changes  of  the 
detrusor  muscle;  wdiile  the  incontinence  is  due  to  the  extension 
of  the  metamorphosis  to  the  sphincter  muscle  of  the  neck  and 
the  compressor  muscle  of  the  urethra,  whereby  they  are  rendered 
incapable  of  withstanding  the  hydraulic  pressure  from  within. 

(5.  In  the  second  place,  atony,  or  local  paralysis,  may  arise  from 
overstretching  of  the  nerves  of  the  bladder,  thereby  constituting 
the  condition  generally  spoken  of  as  atony  from  overdistention 
of  its  muscular  fibres.  This  variety  of  the  affection  is  most 
common  in  advanced  life,  being  often  engrafted  upon  the  pre- 
ceding form;  but  it  may  occur  at  an}'  period,  even  in  the  most 
tender  infancy.  It  is  usually  produced  by  a  neglect  to  empty 
the  organ  w'hen  a  desire  is  felt  to  urinate,  the  patient,  perhaps, 
not  finding  it  convenient  at  the  moment,  or  for  some  time  after, 
to  obey  the  promptings  of  nature.  When  at  length  he  makes 
the  effort,  he  is  unable  to  succeed,  the  muscular  filn-es  refusing 
to  perform  their  duty.  In  short,  they  are  in  a  state  of  paralysis 
from  extension  of  their  nerves,  and  the  most  violent  straining 
is  incapable  of  exciting  them.  Voluntary  retention  is  thus 
succeeded  by  involuntary  retention ;  and  repeated  acts  of  this 
description  are  liable  to  eventuate  in  permanent  inertia.  Old 
men  of  sedentary,  studious  habits,  or  who  take  a  good  deal  of 
exercise  on   horseback,  are  very  lial)le  to  this  form  of  palsy. 


88  FUXCTIOXAL    DISEASES    OF    THE    BLADDER. 

Instead  of  paying  due  regard  to  the  desire  to  urinate,  they 
neglect  it,  and  wlien  the\'  finally  attenijit  to  empty  the  hladder, 
they  are  frequently  unalde  to  pass  a  drop  of  water.  I  have  seen 
numerous  cases  of  this  kind,  some  of  which  terminated  fatally, 
generally  within  the  first  five  or  six  days. 

To  this  class,  that  is  paralysis  or  atony  from  local  nerve  lesions, 
may  be  referred  the  palsy  which  often  follows  severe  and  pro- 
tracted labor,  in  consequence  of  the  pressure  which  the  child's 
head,  as  it  descends  into  the  pelvis,  exerts  upon  the  hladder, 
especially  if  the  urine  has  not  been  previously  evacuated.  In 
these  cases  the  nerves  are  not  only  overstretched  b}'  the  retained 
urine,  but  they  are  subjected  to  compression  by  two  forces,  one  of 
which  acts  from  within  the  bladder,  and  the  other  from  without. 
The  loss  of  power  of  .conduction  on  the  part  of  the  disabled 
nerves,  under  these  circumstances,  is  sometimes  so  great  that 
their  functions  are  not  restored  for  several  weeks. 

Ill  this  section  must  also  be  included  palsy  arising  from 
external  violence.  My  attention  was  first  prominently  directed 
to  this  subject  nearly  twenty  years  ago,  in  consequence  of  being 
called  to  a  patient  who,  in  a  scuffle  with  a  fellow-laborer,  had 
received  a  kick  upon  the  hypogastric  region,  his  bladder  being 
at  the  time  full  of  urine.  He  Avas  seized  soon  after  with  severe 
pain  in  the  pelvis,  accompanied  with  a  stinging  sensation  along 
the  conrce  of  the  urethra,  and  an  utter  inability  to  pass  a  drop 
of  urine.  The  catheter  Avas  introduced  twice  a  day  for  nearly 
a  Aveek  before  the  organ  fully  regained  its  functions.  The  nerves 
and  muscular  fibres  had  evidently  suffered  violent  contusion, 
in  consequence  of  Avhich  the  latter  had  lost  their  poAver  of  con- 
traction. The  occurrence  is  generally  caused  by  the  passage  of 
a  Avheel  of  a  carriage,  by  blows  or  falls,  or  by  the  body  being 
jammed  in  betAveen  tAvo  firm  and  resisting  ol>jects,  as  a  post  and 
a  wagon.  It  is  sometimes  complicated  Avith  fracture  of  the 
pelvic  bones,  and  occasionally  it  supervenes  upon  injury  of  the 
perineum. 

•2.  PamJysis  of  the  Bladder  from  general  c'azfs<?6-.— Paralysis  of 
the  bladder  may  arise  from  functional  or  essential  disorders 
of  the  brain  and  spinal  cord,  the  affection  being  of  central  origin, 
and  entirely  independent  of  any  changes  in  the  organ  itself. 
The  causes  of  this  form  of  i>alsy  may  be  arranged  under  the 
folloAving  heads:  a,  disease  or  injury  of  the  cerebro-spinal  axis  ; 


PARALYSIS  AXD  ATONY  OF  THE  BLADDER.      89 

13,  functional  exhaustion  of  the  nervous  system;  7,  reflex  action  ; 
and,  6,  the  use  of  certain  remedies. 

a.  The  paralysis  dependent  upon  lesion  of  the  brain  and  spinal 
cord  is  nearly  always  associated  with  paraplegia  of  the  lower 
extremities.  The  causes  which  conmionlj-  give  rise  to  this  affec- 
tion are  meningitis,  myelitis,  abscess,  serous  effusions,  extrava- 
sation of  blood,  the  presence  of  gummy  and  other  tumors, 
angular  curvature,  sprains,  concussions,  fractures,  dislocations, 
and  wounds.  In  these  cases,  it  may  exist  in  various  degrees, 
from  a  slight  want  of  muscular  power  to  complete  loss ;  but  it 
is  never  complete  unless  it  is  associated  with  paralysis  of  the 
abdomintd  muscles.  When  the  paralysis  is  confined  to  the  neck 
of  the  bladder,  while  the  rest  retains  its  faculty  of  contracting, 
the  consequence  will  be  incontinence  of  urine.  It  may  disapjiear 
in  a  few  hours  or  a  few  days,  or  it  may  continue  for  months  and 
even  years,  if  not,  indeed,  during  the  rest  of  life.  The  paraplegia 
may  pass  off,  and  the  paralysis  of  the  bladder  alone  remain, 
although  in  general  the  reverse  is  the  case,  the  power  of  urinating 
being  restored  before  that  of  locomotion.  I  have  met  with 
repeated  instances  illustrative  of  the  truth  of  this  remark. 

When  the  paralysis  is  associated  with  paraplegia,  the  sensibility 
of  the  bladder  is  generally  so  much  impaired  that  the  patient  is 
unconscious  of  his  situation.  He  suffers  no  pain  or  inconvenience, 
and  does  not  complain  of  any  derangement  of  the  urinary  appa- 
ratus. The  bladder,  in  truth,  is  a  mere  passive  reservoir,  which 
often  becomes  enormously  distended  before  any  one  is  apprised 
of  its  condition.  It  is  a  matter  of  paramount  importance,  t*here- 
fore,  in  all  cases  of  injury  of  the  spine  and  brain,  that  the  prac- 
titioner should  ascertain,  at  every  visit,  whether  the  patient  can 
void  his  urine,  or  whether  it  is  retained  in  the  bladder.  He 
should  be  careful,  moreover,  not  to  mistake  the  dribbling,  which 
almost  always  exists  in  these  cases  after  the  first  three  or  four 
days,  for  incontinence.  When  a  certain  degree  of  sensibility 
remains,  the  pelvic  pains,  the  constant  desire  to  urinate,  and  the 
sense  of  weight  and  distention  in  the  hypogastric  region,  usually 
sufficiently  indicate  the  nature  of  the  complaint.  In  nearlj-  all 
instances  the  palsy  comes  on  immediately  after  tbe  accident  that 
produces  the  paraplegia,  and  in  fatal  cases  obstinately  persists 
to  the  last." 

When  the  paralysis  of  the  bladder  is  produced  b}'  injur}-  of 


90  FUNCTIONAL    DISEASES    OF    THE    BLADDER. 

the  spinal  cord,  the  urine  is  usually  highly  alkaline,  turbifl,  of 
an  ammoniacal  odor,  and  surcharged  with  thick,  ropy  mucus, 
riiosphatic  matter  soon  makes  its  appearance ;  inflammation  is 
speedily  set  up  in  the  lining  membrane ;  and,  if  the  patient  sur- 
vive any  time,  ulceration  frequently  takes  place,  folhnvecl  by  a 
discharge  of  blood,  and  even  pus.  Persons  thus  aflfected  are 
very  prone  to  calculous  disease:  in  some  instances  the  whole  of 
the  inner  surface  of  the  bladder  is  incrusted  with  calcareous 
matter.  AVhen  the  injury  is  seated  in  the  dorsal  region,  above 
the  tenth  vertebra,  priapism  is  not  uncommon. 

p.  Paralysis  of  the  bladder  is  frequently  Avitnessed  during  the 
progress  of  low  fevers,  as  typhus,  in  which  there  is  temporary 
functi<mal  derangement,  probably  of  the  restiform  bodies  of  the 
medulla  oldongata.  The  affection,  indeed,  is  much  more  com- 
mon than  is  usually  supposed,  and  is  unfortunately  often  over- 
looked by  the  professional  attendant.  From  ignorance  of  the 
subject,  or,  what  is  equally  culpable,  inattention,  much  suflering 
is  thus  sometimes  produced ;  the  primary  disease  is  greatly 
affo^ravated,  and  life  is  brought  into  imminent  dano-er.  The 
paralysis  may  occur  at  any  period  of  the  febrile  complaint ;  but 
is  most  apt  to  show  itself  in  the  advanced  stages,  when  there  is 
considerable  depression  of  the  nervous  system.  The  first  link 
in  the  morbid  chain  seems  to  be  a  want  of  sensibility  of  the 
bladder,  in  consequence  of  which  the  urine  ceases  to  make  its 
accustomed  impression,  and  continues  to  accumulate  without 
awakening  any  desire  to  evacuate  it.  When  at  length  the  pro- 
per inclination  is  felt,  the  muscular  fibres  will  be  found  to  have 
been  so  much  stretched  that  they  are  incapable  of  fulfilling  their 
offtce.  The  patient,  lying  in  a  state  of  stupor,  drowsiness,  or 
delirium,  is  unable  to  indicatehis  wants,  and  thus  the  distention 
goes  on  increasing  until  the  bladder  is  in  danger  of  bursting. 
When  some  degree  of  sensibility  remains,  he  makes  knoAvn  his 
suffering  by  his  moans  and  restlessness,  and  by  placing  the  hand 
upon  the  hypogastric  region,  by  grasping  the  penis,  or  by  making 
ineffectual  efforts  to  void  his  urine.  In  complete  insensibility, 
he  is  unconscious  of  any  inconvenience. 

In  this  division  of  the  subject  may  be  included  the  palsy  which 
results  from  functional  spinal  debility,  caused  by  inordinate 
sexual  indulgence,  or  long-continued  onanism.    The  defect,  which 


PARALYSIS  AXD  ATOXY  OF  THE  BLADDER.      91 

!.■*  most  common  in  old  men,  occasionally  occurs  in  young  subjects, 
and  rarely  exists  in  a  complete  degree. 

y.  Paralysis  from  reflex  irritation  is  not  uncommon,  particu- 
larly after  operations  for  hemorrhoids.  It  occasionally'  super- 
venes upon  compound  fractures  and  dislocations,  severe  injuries 
of  the  lower  extremities,  wounds  of  the  bowels,  strangulated 
hernia,  and  contusions  of  the  walls  of  the  abdomen.  Every 
surgeon  is  aware  that  the  bladder  sometimes  loses  its  power  of 
contraction  after  amputation  of  the  thigh  and  leg,  the  removal 
of  large  tumors,  and  other  important  operations. 

5.  Great  torpor  of  the  bladder,  amounting  to  actual  paralysis, 
may  follow  the  use  of  opium,  hyoscyamus,  and  belladonna.  The 
paralysis,  generally  slight  at  first,  may  ultimately,  by  a  con- 
tinuance of  the  remed}',  become  so  complete  as  to  require  the 
catheter  for  the  evacuation  of  the  urine. 

Whatever  may  be  the  cause  of  the  paralysis,  or  the  circum- 
stances under  which  it  takes  place,  the  sj^mptoms  which  attend 
it  are,  in  general,  sufficientlj^  well  marked.  As  soon  as  the 
l)ladder  has  lost  its  power  of  contraction,  its  contents  accumu- 
late and  distend  its  walls.  The  organ,  thus  pressed  upon  in 
every  direction,  gradually  rises  above  the  pubes  into  the  hypo- 
gastric region,  forming  a  tumor  which  ascends  sometimes  as 
high  as  the  umbilicus,  and  as  far  outwards  on  each  side  as  the 
brim  of  the  pelvis.  The  swelling  is  of  an  ovoidal  shape,  fluctu- 
ating, indolent  at  first,  but  painful  afterwards,  and  attended  with 
complete  retention,  which  constitutes  the  characteristic  symptom 
of  the  affection.  After  the  paralysis  has  continued  for  several 
days,  the  water  generally  dribbles  off  in  drops,  and  thus  incon- 
tinence is  added  to  the  retention.  It  is  to  this  form  of  retention 
that  I  applied,  twenty-five  years  ago,  the  term  incontinence  of 
retention,  whicli  is  synonymous  with  the  more  modern,  but  less 
appropriate,  expression,  engorgement  with  overflow,  in  the  hope 
of  attracting  particular  attention  to  it.  In  the  milder  forms  of 
the  malady,  the  power  of  contraction  is  only  dirninislied,  not 
entirely  lost,  and  a  portion  of  the  urine  is  still  voided,  under  the 
influence  of  the  will,  either  at  regular  or  remote  intervals.  The 
duration  of  the  paralysis  varies  from  a  few  hours  or  days  to 
several  weeks,  months,  or  even  years.  Occasionally  it  ceases 
ou\y  Avith  life. 

It  is  unnecessary  to  give  a  detailed  account  of  the  changes  ob- 


92  FUXCTIONAL    DISEASES    OF    THE    BLADDER. 

served  in  this  disease  after  death.  As  in  other  vesical  affections, 
signs  of  congestion  or  of  inflammation  are  generally  discovered 
in  various  parts  of  the  lining  membrane ;  the  muscular  fibres 
are  pale  and  indistinct,  and  the  parietes  of  the  organ  are  remark- 
abl}-  thin,  flal)by,  and  attenuated.  In  some  instances,  blackish, 
dark-colored,  or  grayish  spots  are  visible,  and  are  evidently  the 
effect  of  incipient  gangrene.  In  neglected  cases,  or  in  those 
which  run  their  course  very  rapidly,  the  different  coats  are 
very  much  softened,  and  hence  they  sometimes  give  way  at  one 
or  more  points,  followed  by  an  escape  of  the  urine  into  the 
general  peritoneal  cavity.  "When  the  paralysis  is  of  long  stand- 
ing, it  is  not  unusual  to  meet  with  ulcers  and  phosphatic 
incrustations  of  the  mucous  membrane.  Disease  of  the  asso- 
ciated organs  is  by  no  means  uncommou,  but  does  not  form  a 
necessary  concomitant  or  consequence. 

The  prognosis  of  vesical  paralysis  can  be  correctly  estimated 
only  by  an  attentive  consideration  of  its  causes.  !Much  will 
also  necessarilj^  depend  upon  the  treatment,  the  age  of  the 
patient,  the  state  of  the  system,  and  the  duration  of  the  disease. 
When  the  retention  of  urine,  which  constitutes,  as  has  been 
already  stated,  the  characteristic  symptom  of  the  affection,  is 
not  early  relieved,  a  long  time  must  necessaril}'  elapse  before 
the  elongated  and  overstretched  fibres  will  regain  their  former 
vigor.  When  the  distention  continues  in  full  force  for  four  or 
five  days,  the  tone  of  the  organ  is  liable  to  be  destroyed  for  life  ; 
indeed,  such  cases  often  speedily  terminate  in  death,  even  when 
the  most  urgent  symptom  has  been  relieved  by  the  catheter. 
An  instance  in  point  occurred  to  me  in  a  gentleman  of  sixty, 
who  had  labored  under  paralysis  of  the  bladder,  with  complete 
retention,  from  Monday  at  twelve  o'clock  until  nearly  the  same 
hour  on  Thursday  night.  I  had  no  difficulty  in  passing  the 
catheter ;  upwards  of  a  quart  of  water  was  drawn  off,  and  the 
patient  felt  himself  immensely  relieved  in  a  few  minutes.  Not- 
withstanding he  rested  well  during  the  remainder  of  the  night, 
and  had  a  good  pulse  when  I  took  my  leave  of  him  in  the 
morning  after  a  late  breakfast,  he  died  early  the  following 
Saturday  evening,  in  a  state  of  complete  exhaustion.  ISTo 
examination  was  made ;  but  the  probability  was,  as  I  learned 
from  the  attending  physician,  that  there  was  partial  gangrene 
of  the   suffering   organ.      When    the   paralysis  depends   upon 


PARALYSIS  AXD  ATOXY  OF  THE  BLADDER.      93 

organic  lesion  of  the  brain  or  spinal  cord,  or  upon  permanent 
compression  of  the  bladder  or  of  the  nerves  which  siipplj-  its 
tunics,  it  may  generally  be  regarded  as  incurable.  Recovery 
will  be  more  probable  in  young  than  in  old  subjects,  and  in 
recent  than  in  old  cases. 

It  must  be  obvious  that  an  affection  depending  upon  so  many 
and  such  opposite  causes,  must  require,  for  its  removal,  a  variety 
of  modes  of  treatment.  The  first  inquiry,  in  all  cases,  should, 
therefore,  be,  how  has  the  malady  been  induced?  Upon  the 
proper  solution  of  this  question  must  necessarily  hinge  the  suc- 
cess of  our  curative  agents. 

Two  important  indications  are  presented  in  every  case  of  this 
disease  ;  first,  to  draw  off  the  urine,  and  secondly,  to  restore  the 
tone  of  the  muscular  fibres  of  the  affected  organ.  To  fulfil  the 
first,  all  that  is  necessary  is  to  use  the  catheter.  This  should 
be  done  every  six  or  eight  hours,  to  prevent  undue  accumula- 
tion, and  to  compel  the  viscus  to  return,  as  it  were,  to  its 
original  habits.  Carefully  persevered  in,  this  practice  is  fre- 
quently of  itself  sufficient,  in  a  short  time,  to  cure  the  malady. 
When  complete  paralysis  of  the  abdominal  muscles  is  associated 
with  the  vesical  trouble,  through  which  their  assistance  in 
emptying  the  viscus  is  lost,  it  may  be  necessary  to  favor  expul- 
sion by  making  pressure  over  the  region  occupied  by  the  dis- 
tended bladder.  As  this  procedure,  however,  is  objectionable, 
the  difficulty  may  be  obviated  by  attaching  a  piece  of  gum 
tubing  to  a  catheter  with  a  double  curve,  through  which  the 
action  of  a  siphon  is  imitated.  I  generally  prefer  introducing 
the  catheter  every  time  it  is  necessary  to  draw  off  the  urine  to 
letting  it  remain  in  the  bladder  permanently ;  and  as  there  is 
seldom  any  difficulty  in  doing  this,  the  patient  usually  soon 
learns  to  perform  the  operation  himself.  Sometimes,  however, 
the  improvement  is  more  rapid  and  decided  wlien  the  catheter 
is  constantly  retained,  and  the  water  permitted  to  flow  off"  every 
hour  or  two.  I  have  found  this  practice  particularly  useful  in 
cases  of  paralysis,  attended  with  pain  and  spasm  of  the  neck  of 
the  bladder,  and  a  frequent  desire  to  urinate.  When  the  accu- 
mulation is  very  great,  and  has  continued  for  several  days,  it  is 
a  good  rule  not  to  evacuate  all  the  water  at  once,  for  fear  of 
inducing  severe  depression  from  the  sudden  removal  of  the 
stimulus  of  distention.     I  have  seen  several  cases  in  whicli  I  am 


94  FUXCTIOXAL    DISEASES    OF    THE    BLADDER. 

satisfied  the  patients  lost  their  lives  from  inattention  to  this 
precantion.  My  own  custom,  under  such  circumstances,  is  not 
only  to  allow  a  small  quantity  of  urine  to  remain,  but  to  support 
the  weakened  organ  by  swathing  the  abdomen,  precisely  as 
after  parturition,  and  tapping  in  ascites.  When  the  catheter  is 
})ermanently  left  in  the  bladder,  it  should  be  confined  in  the 
usual  manner,  and  cleaned  every  other  day ;  otherwise  it  will 
be  certain  to  become  incrusted  with  inspissated  mucus,  if  not 
with  earthy  matter,  and  thus  produce  an  injurious  impression 
upon  the  aft'ected  organ. 

Much  harm  is  often  done  in  this  disease  by  the  protracted 
employment  of  the  catheter.  The  proper  plan  is  always  to  dis- 
continue it  as  soon  as  the  organ  has  regained  its  expulsive 
power.  The  patient  should  be  requested  from  time  to  time  to 
try  to  evacuate  the  bladder  by  his  own  efforts,  and  if  he  is  not 
able  to  ett'ect  the  object  completely,  he  should  be  assisted  with 
the  catheter ;  for  the  rule  i-^,  in  all  cases,  to  draw  off  everj'  par- 
ticle of  Avater  at  least  twice  in  the  twenty-four  hours.  By 
employing  the  instrument  too  long,  the  organ  becomes  habituated 
to  its  use,  and  the  cure  will  necessarily  be  more  protracted. 

The  second  indication,  which  is  to  impart  tone  to  the  bladder, 
or  reanimate  its  exhausted  energies,  may  be  fulfilled  in  various 
ways.  It  has  been  already  seen  that  the  regular  evacuation  of 
the  urine  is  sometimes  of  itself  sutiicient  to  answer  this  purpose ; 
in  general,  however,  it  has  to  be  aided  by  other  means,  both  of 
a  constitutional  and  a  local  character,  and  it  is  not  always  easy 
to  determine  which  of  these  is  entitled  to  the  greater  share  of 
the  credit. 

Among  the  remedies  which  ought  to  be  mentioned  first  are 
cathartics,  which  constitute  a  most  valuable  class  of  asents  in 
nearly  all  cases  of  this  disease,  no  matter  what  may  he  its  exciting- 
cause.  A  brisk  cathartic,  consisting  of  calomel  and  jalap,  or 
calomel,  and  compound  extract  of  colocynth,  will  often  produce 
the  most  prompt  and  happy  efifect,  not  only  ridding  the  alimen- 
tary canal,  perhaps,  of  much  vitiated  and  ofiensive  matter,  but 
improving  the  secretions,  and  rousing  the  energies  of  the  whole 
system.  The  dose  may  be  repeated  every  other  day,  until  a 
decided  amendment  takes  place,  when  it  should  be  administered 
at  longer  intervals,  and  with  a  more  sparing  hand. 

Emetics  are  sometimes  of  signal  benefit  in  this  disease.     They 


PARALYSIS  AXD  ATOXV  OF  THE  BLADDER.      95 

are  partieularh'  valuable  where  the  paralysis  is  coincident  with 
disorder  of  the  digestive  organs  and  torpor  of  the  general  system. 
They  are  contraindicated  in  the  traumatic  form  of  the  disease, 
whether  dependent  upon  direct  injury,  or  indirectly  upon  injury 
of  the  brain  and  spinal  cord. 

After  the  bowels  have  been  w^ell  evacuated,  and  the  secretions 
restored,  recourse  may  be  had  to  remedies  calculated  to  make  a 
more  direct  impression  upon  the  nervous  system,  if  not  upon  the 
suffering  organ  itself.  At  the  head  of  this  class  of  agents  may 
be  placed  strychnia,  cantharides,  and  arnica.  Witlj  the  excep- 
tion of  the  inflammatory  form  of  the  affection,  there  is  liardlj-  a 
case  of  vesical  paralysis  in  which  these  remedies  may  not  be  em- 
ployed with  a  fair  prospect  of  benefiting  the  patient.  The}'  may 
be  used  either  separately,  or,  as  I  generally  prefer,  in  combination 
with  each  other.  Given  in  this  manner,  their  eftcct  is  usually 
more  prompt  and  decided  than  when  they  are  administered  alone. 
An  excellent  formula,  is  the  twentieth  of  a  grain  of  strychnia, 
the  fourth  of  a  grain  of  cantharides,  and  from  three  to  five  grains 
of  the  extract  of  arnica,  three  times  in  the  twenty-four  hours  ; 
care  being  taken  to  watch  their  eftect,  and  to  diminish  or  augment 
the  quantity  of  the  respective  articles,  as  circumstances  may 
seem  to  indicate.  If  spasmodic  twitchings  ensue,  the  [latient 
suffer  from  strangury,  or  the  stomach  become  irritable,  they  are 
to  be  regarded  as  an  evidence  that  they  have  been  carried  far 
enough,  that  the  dose  should  be  modified,  or  that  the  oftending 
substance  should  be  temporarily  suspended  ;  to  be  resumed,  if 
necessary,  at  another  period.  In  paralysis  of  the  bladder,  conse- 
quent upon  typhoid  and  other  fevers,  venereal  excesses,  and 
general  exhaustion,  few  remedies  are  so  serviceable  as  arnica, 
administered  in  the  form  of  the  tincture,  in  doses  of  from  forty 
to  sixt}^  drops  three  times  a  day. 

Strong  testimony  has  been  published  in  favor  of  ergot  of 
rye  in  the  treatment  of  this  affection;  and  of  its  efficacy  I  can 
speak  strongly  from  personal  experience.  A  convenient  mode 
of  administration  is  the  fluid  extract,  the  dose  being  a  drachm 
three  times  a  day. 

When  the  disease  is  associated  with  general  debility,  tonics 
are  indicated,  and  often  exert  an  excellent  eftect,  botli  upon  the 
system  at  large,  and  upon  the  urinary  bladder.  In  general,  a 
preference  is  conceded  to  the  chalybeate  preparations,  of  which 


96  FUXCTIOXAL    DISEASES    OF    THE    BLADDEK. 

the  best  is  the  tincture  of  the  chloride  of  iron,  in  closes  of 
t\vent\-  drops  every  six  or  eight  hours.  It  may  be  combined 
witli  strychnia,  quinine,  arnica,  and  other  articles,  if  it  be  deemed 
necessary. 

Counter  irritation  is  a  useful  auxiliary  to  the  other  remedies. 
Indeed,  there  is  scarcely  any  form  of  vesical  paralysis  in  which 
it  will  not  prove  more  or  less  advanta2:eous.  In  rebellious  cases, 
the  actual  cautery  is  a  most  powerful  and  suitable  agent.  The 
iron,  which  should  be  fully  one  inch  in  diameter,  should  be 
applied  to  the  lower  lumbar  region,  and  the  discharge  be  main- 
tained, if  necessary,  for  many  weeks. 

Another  remedy  of  great  potency,  in  many  cases  of  this  dis- 
ease, is  the  cold  douche.  It  is  a  most  powerful  stimulant,  and 
sometimes  rouses  the  dormant  energies  of  the  bladder  when 
almost  everything  else  has  failed.  The  water  should  be  poured 
from  a  pitcher  held  at  a  height  of  three  or  four  feet,  alternately 
upon  tlie  hypogastric  region  and  the  inferior  portion  of  the  spine, 
for  a  few  minutes  at  a  time,  and  the  application  should  be  imme- 
diately followed  by  frictions  with  a  coarse  dry  towel  until  there 
is  a  perfect  glow  upon  the  surface.  Sponging  the  loins,  hips, 
and  pubic  region  morning  and  evening  with  cold  salt  water,  and 
rubbing  them  afterwards  with  a  tolerably  hard  flesh-brush,  has 
sometimes  a  happy  effect.  The  same  is  true  of  injections  of 
cold  water  into  the  rectum. 

The  local  treatment  of  paralysis  of  the  bladder  should  be  di- 
rected to  the  restoration  of  the  contractile  power  of  its  muscular 
fibres,  on  the  same  principle  that  artificial  exercise  is  given  to 
paralyzed  muscles  of  other  parts  of  the  body.  Long  after  the 
existing  cause  has  apparently  disappeared,  the  bladder  often  re- 
mains inactive  in  consequence  of  degeneration  of  its  nervous  and 
muscular  elements.  To  induce  artificial  action,  warm  water, 
followed  by  cold,  may  be  thrown  into  the  viscus,  alternating 
douches  of  different  temperatures  making  a  more  powerful  im- 
pression than  cold  injections  alone.  These  means  are  especialh' 
called  for  when  the  disease  is  accompanied  by  cystorrhoea,  but, 
under  these  circumstances,  warm  fluids  alone  should  be  employed. 

Injections  of  strychnia  are  worthy  of  trial  in  this  affection. 
In  a  very  rebellious  case,  occurring  in  a  man,  sixty-eight  years 
of  age,  who,  after  a  drinking  bout  and  exposure  to  cold,  found 
himself  unable  to  void  his  urine,  every  known  method  of  treat- 


PARALYSIS  AND  ATONY  OF  THE  BLADDER.     97 

ment  had  proved  inefFectual.  At  the  end  of  ten  weeks,  Dr. 
Lecluyse'  dissolved  six  grains  of  stryclmia,  with  a  little  alcohol, 
in  a  pint  of  water,  and  of  this  solution  he  injected  into  the 
bladder,  previously  emptied,  two  ounces  four  times  a  day.  No 
effect  was  perceptible  until  about  the  end  of  the  fifth  day,  when 
some  urine  appeared  between  the  catheter,  which  had  been 
retained  in  the  bladder,  and  the  urethra.  The  instrument  beino; 
removed,  the  patient  found  that  he  had  regained  complete 
voluntary  command  over  the  organ;  and  from  this  time  on  he 
experienced  no  further  inconvenience. 

Dr.  Tarbell,^  of  China,  recently  effected  a  cure  by  throwing 
into  the  bladder  the  one-sixteenth  of  a  grain  of  the  alkaloid  in 
about  four  drachms  of  water,  a  copious  voluntary  flow  of  urine 
taking  place  after  the  third  injection,  or  fourteen  hours  from 
the  commencement  of  the  use  of  the  remedy.  The  case  was  one 
of  paralysis  from  parturition,  in  which  the  catheter  had  been 
employed  every  twelve  hours  for  twenty  days. 

Finally,  electricity,  in  the  form  of  galvanism  or  faradism, 
should  not  be  neglected  as  a  local  stimulant.  It  may  be  applied 
directly  to  the  bladder  or  externally.  In  the  former  method, 
an  insulated  conductor  is  introduced  into  the  previously 
emptied  viscus,  and  a  weak  current  passed  to  an  ordinary 
moistened  sponge  electrode  applied  over  the  lumbar  spine,  the 
perineum,  or  the  hypogastrium,  or  to  these  points  in  succession. 
Tiie  application  should  not  be  continued  longer  than  five  minutes 
twice  a  day.  In  the  indirect  method,  the  negative  reophore 
should  be  applied  to  the  back  of  the  head,  and  the  positive  to 
the  suprapubic  region,  when  there  is  reason  to  believe  that  the 
paralysis  is  due  to  disorder  of  the  peduncles  of  the  brain,  as 
occurs  in  low  fevers.  When  the  affection  depends  upon  disease 
of  the  lumbar  portion  of  the  spinal  cord,  the  negative  electrode 
is  placed  in  that  locality,  while  the  positive  one  is  applied  to  the 
hypogastrium.  In  local  paralysis,  or  atony,  both  poles  may  be 
placed  above  the  pubes.  Faradisation  of  the  full  bladder  some- 
times answers  a  better  purpose  than'  when  the  organ  is  empty. 

'  Annales  de  la  Society  d'Emulation  de  la  Flaudre  Occidentalc,  1850. 
2  Medical  Record,  Nov,  13,  1875,  p.  767. 
7 


CHAPTER   IV. 

INCONTINENCE  OF  URINE. 

Incontinence  of  urine,  or  enuresis,  is  most  common  iu  children 
and  old  persons;  but  it  may  occur  at  any  period  of  life,  and  may 
be  partial  or  complete,  temporary  or  permanent.  The  water 
may  pass  off"  as  fast  as  it  is  secreted,  or  it  may  be  retained  for  a 
time,  and  then  either  dribble  away,  or  be  discharged  in  a  full 
stream.  It  is  in  general  a  A^ery  distressing  affection,  for  the 
constant  discharge  not  only  keeps  the  clothes  wet,  but  it  excoriates 
the  genital  organs  and  thighs,  and  thus  leads  to  much  suffering. 
The  smell  is  also  extremely  offensive.  It  may  be  excited  by  a 
a;reat  variety  of  circvimstances,  the  most  prominent  of  which, 
however,  are  referable  to  external  injury,  or  to  inflammation, 
spasm,  paralysis,  or  morbid  sensibility  of  the  bladder,  or  of  this 
organ  and  the  urethra,  and  organic  changes  in  the  prostate  gland. 
Temporary  enuresis  is  sometimes  caused  by  mental  emotions, 
such  as  fear  and  excitement,  of  which  I  have  met  with  numerous 
examples  in  medical  students  who  were  about  to  undergo  their 
examinations  for  the  doctorate.  It  is  also  occasionally  induced 
by  gout  or  rheumatism.  The  affection  may  be  feigned  by 
soldiers  to  escape  tlie  performance  of  military  duty ;  when  the 
imposition  may  sometimes  be  detected  by  the  threatened  applica- 
tion of  the  actual  cautery.^ 

a.  The  best  example  of  incontinence  from  external  injury  is 
afforded  in  lithotomy,  the  difficulty  being  most  distressing  in  the 
day,  while  the  pei*son  is  in  the  erect  posture.  In  this  variety  of 
enuresis,  there  is  evidently  partial  loss  of  power  of  the  muscular 
fibres  at  the  neck  of  the  bladder,  associated  with  hyper?esthesia 
<^f  the  mucous  membrane.  A  kick,  bloAv,  or  fall  upon  the  peri- 
neum is  occasionally  followed  by  the  same  result.  In  the  female, 
the  operation  of  lithotomy,  or  slow  dilatation  of  the  urethra,  is 
extremely  liable  to  be  succeeded  by  incontinence ;  while  in  the 
male  the  passage  of  large  bougies  produces  atony  or  relaxation 

'  Beck's  Medical  Jurispnuleuce,  vol.  i.  p.  60,  1860. 


INCOXTINEXCE    OF    URINE.  99 

of  the  vesical  sphincter,  and  consequent  drihbling.  The  affection 
often  disappears  spontaneously ;  or,  on  the  other  hand,  it  is  some- 
times incurable.  The  treatment  must  be  conducted  on  general 
principles.  Compression  of  the  perineum  with  a  spring  truss  is 
worthy  of  a  trial. 

s.  Incontinence  from  inflammation,  common  or  specific,  of 
the  bladder  and  urethra,  and  its  effects,  may  depend  upon  various 
circumstances,  as  external  injury,  the  extension  of  gonorrhoea, 
strong  injections,  calculus,  prostatitis,  stricture  of  the  urethra, 
and  syphilitic  or  tubercular  ulceration,  giving  rise  to  loss  of 
substance  at  the  neck  of  the  bladder.  Mr.  Langston  Parker, 
of  Birmingham,  states  that  he  has  had  one  or  two  patients  in 
whom  an  incurable  incontinence  of  urine  had  been  brought 
on  by  large  doses  of  coi)aiba.^  This  variety  of  enuresis  is 
very  common  in  callous  strictures,  particularly  of  the  mem- 
branous urethra,  in  which  the  fibres  of  its  compressor  mnscle 
are  converted  into  an  inelastic  structure,  thereby  depriving  it  of 
its  function  as  an  external  sphincter.  It  is  also  a  constant 
attendant  of  concentric, hj'pertrophy  of  the  bladder,  a  condition 
marked  by  a  diminution  of  the  capacity  of  the  organ,  and  its 
consequent  inability  to  retain  more  than  a  small  quantity  of 
urine.  In  many  of  the  foregoing  cases  the  escape  is  usually 
partial,  and  is  almost  constantly  associated  with  spasm ;  while 
in  others,  the  dribbling  is  constant.  The  treatment  consists  in 
removing  the  exciting  cause.  The  catheter  often  affords  instan- 
taneous relief.  When  the  discharge  is  troublesome,  or  incessant, 
the  patient  should  wear  a  urinal. 

7.  Paralj'sis  of  the  bladder,  or  of  this  viscus  and  the  urethra, 
however  induced,  is  a  frequent  cause  of  that  false  form  of  incon- 
tinence, which  I  have  termed  incontinence  of  retention.  As 
tliis  symptom  is  fully  considered  in  the  preceding  chapter,  it 
need  only  be  mentioned  at  this  time.  To  this  class  may  be 
referred  the  incontinence  which  depends  upon  atony  or  relaxa- 
tion of  the  sphincter  nmscle  of  the  bladder,  from  spinal  debility 
induced  Iw  masturbation,  or  inordinate  sexual  indulgence. 

6.  Incontinence  may  arise  from  liypertesthesia  of  the  neck  of 
the  bladder,  or  of  the  entire  organ,  or  of  the  former  locality  and 
}irostatic  urethra,  excited  by  a  dense  and  acrid  state  of  the  urine, 

'  Modern  Treatment  of  Syphilitic  Diseases,  2d  ed.,  London.  IS.")'),  p.  ."il. 


100  INCONTINENCE    OF    URINE. 

or  by  sy]npathy  with  the  kidney,  rectum,  anus,  vagina,  or  uterus. 
In  the  early  months  of  pregnancy,  the  woman  is  often  tormented 
with  a  constant  desire  to  urinate,  and  if  the  inclination  be  not 
instantly  gratified,  the  water  flows  off  involuntarily.  "Worms 
in  the  lower  bowel,  hemorrhoids,  fissure  of  the  anus,  congenital 
phimosis,  and  contracted  meatus,  are  often  attended  with  enuresis. 
In  all  of  these  instances,  the  sensory  nerves  transmit  the  impres- 
sion of  a  desire  to  urinate  to  tlie  brain,  whence  it  is  carried  back 
by  the  motor  nerves,  thereby  inducing  functional  disturbance  of 
the  bladder,  as  indicated  by  involuntary  contraction  of  its  de- 
trusor muscle.  It  the  morbid  sensibility  be  long  continued,  it  is 
inevitably  followed  by  atony  of  the  vesical  sphincter. 

To  this  form  of  incontinence  obviously  belongs  the  nocturnal 
variety  of  the  disease  which  occurs  in  young  subjects.  It  is 
most  common  in  delicate  boys  before  the  age  of  ten,  and  often 
beo-ins  much  earlier.  The  discharge,  which  may  take  place 
twice  or  even  thrice  during  the  night,  is  sometimes  eflTected 
under  the  influence  of  the  will  or  a  dream,  but  in  general  it  is 
strictly  involuntary.  "When  it  becomes  habitual,  as,  in  fact  it 
usually  does,  it  may  last  for  years,  and  be  even  prolonged  into 
advanced  life,  although  in  most  cases  it  gradually  disappears  on 
the  approach  of  adolescence.  It  is  promoted  by  the  use  of  fluids, 
by  exposure  to  cold,  and  by  sleeping  on  the  back,  a  posture  which 
is  favorable  to  tlie  accumulation  of  urine  in  the  morbidly  sensi- 
tive portion  of  the  bladder. 

The  pathology  of  this  aflection  consists,  as  has  been  already 
stated,  in  an  exaltation  of  the  natural  sensibility  of  the  mucous 
membrane  of  the  neck  of  the  bladder,  unaccompanied,  in  many 
cases,  by  any  appreciable  change  of  structure.  Sometimes  there 
is  slight  thickening  of  the  part,  and  occasionally  the  affected 
surface  is  somewhat  inflamed.  In  protracted  cases,  there  may 
be  hypertrophy  of  the  prostate  gland,  though  never  to  any  con- 
siderable extent.  The  sphincter  of  the  bladder  is  easily  relaxed, 
and  yields  to  the  most  trifling  impulse ;  hence  the  urine  often 
flows  off"  even  when  there  is  no  fulness  or  distention  of  the 
organ. 

Dr.  Addinell  Hewson  has  reported  some  interesting  facts  in 
relation  to  an  epidemic  of  nocturnal  incontinence,  which  occurred 
in  1857,  in  the  Philadelphia  House  of  Refuge.  Of  78  boys,  or 
nearly  one-fourth  of  the  entire  number  in  the  house,  whose  ages 


INCONTINENCE    OF    URINE.  101 

ranged  from  seven  to  eighteen  years,  the  average  heing  thirteen, 
63  were  under  constant  observation  ;  24  sutfered  from  ascarides; 
20  labored  under  constipation  ;  18  acknowledged  masturbation; 
some  liad  herpes ;  and  many  complained  of  disorder  of  the 
digestive  organs.  The  urine  deposited  lithic  acid  in  nearly  one- 
half  of  the  cases  ;  and  the  prepuce  Avas  elongated  and  discolored, 
either  from  frequent  scratching  or  pulling,  in  46  cases. 

In  the  treatment  of  this  form  of  incontinence,  particular  in- 
quiry should  be  made  into  the  nature  of  the  exciting  cause,  the 
removal  of  which  is  of  paramount  importance.  In  that  variety 
of  the  affection  which  is  met  Avith  in  boys  and  girls,  the  cure 
may  be  greatl^^  expedited  by  proper  attention  to  the  diet,  which 
should  alwaj'S  be  bland  and  unirritant.  Late  suppers  are  to  be 
avoided,  and  the  patient  must  abstain  entirely  from  drinks  for 
several  liours  before  going  to  bed.  During  the  day,  he  must  be 
encouraged  in  the  habit  of  retaining  his  urine  as  long  as  possi- 
ble ;  while  during  the  night,  he  is  to  be  awakened  two  or  three 
times  for  the  purpose  of  emptying  his  bladder,  and  this  practice 
is  to  be  persisted  in  for  weeks  and  even  months,  until  the  dis- 
agreeable habit  is  broken  up.  During  all  this  time,  as  well  as, 
indeed,  for  a  long  period  afterAvards,  the  child  should  lie  upon 
his  side  or  bell}^,  to  prevent  the  urine  from  coming  in  contact 
with,  and  irritating  the  neck  of  the  bladder.  The  internal 
remedies  from  which  I  have  derived  most  benefit,  are  strychnia 
and  cantharides,  given  three  times  a  day,  in  the  proportion  of 
the  fortieth,  or  thirtieth  of  a  grain  of  the  former  to  the  twentieth 
of  a  grain  of  the  latter,  according  to  the  age  of  the  subject.  A 
minute  portion  of  opium  forms  a  valuable  addition  ;  and,  in 
atonic  cases,  I  often  combine  wnth  these  articles  the  tincture  of 
the  chloride  of  iron.  When  the  strychnia  disagrees,  or  fails  to 
answer  the  purpose,  the  extract  of  nux  vomica  may  be  substi- 
tuted for  it.  In  either  case,  it  is  important  to  watch  the  effects 
of  the  remedy.  I  have  great  confidence  in  the  use  of  cantharides 
in  this  affection,  and  have  known  it  to  afford  relief  when  every- 
thing else  seemed  to  prove  unavailing.  I  prefer  the  powder  to 
the  tincture,  and  occasionally  continue  the  exhibition  of  it  until 
slight  strangury  is  induced.  During  the  last  few  years,  chloral 
hydrate  has  heen  greatly  extolled  in  cases  of  this  kind.  It  cer- 
tainly sometimes  speedily  arrests  the  complaint  when  everything 
else  fails,  and  possesses  remarkable  controlling  influence  wlien 


102  IXCOXTIXEXCE    OF    UKIXE. 

there  is  hyperfesthesia  of  the  neck  of  the  bladder.  When  the 
morbid  sensibility  is  connected  with  inflammation,  the  balsam 
of  copaiba,  in  doses  of  from  five  to  ten  drops  every  eight  hours, 
is  sometimes  highly  beneficial.  In  large  doses,  it  is  sure  to  irri- 
tate the  stomach,  and  to  disagree  with  tlie  urinary  organs.  In 
this  variety  of  the  aftection,  a  full  anodyne  at  night,  es[)ecially 
in  the  form  of  Dover's  powder,  often  exerts  a  happy  etfect  in 
controlling  the  discharge.  As  auxiliary  measures,  the  cold 
shower-bath  should  be  used  once  or  twice  a  day,  or  cold  water 
poured  from  a  considerable  height  upon  the  lower  portion  of  the 
spine,  and  blisters  applied  to  the  sacrolumbar  region,  the  peri- 
neum, or  the  inside  of  the  thighs.  In  obstinate  cases,  the  neck 
of  the  bladder  is  cauterized,  as  in  spermatorrhoea,  but  much  more 
mildly,  on  account  of  the  more  tender  age  of  the  patient.  In 
the  female,  the  application  is  made  to  the  orifice  of  the  urethra. 

Belladonna  is  regarded  by  many  practitioners  as  a  panacea  in 
the  incontinence  of  children ;  but  my  experience  is  altogether 
opposed  to  such  a  sweeping  conclusion.  It  may  be  administered 
in  the  form  of  the  extract,  in  doses  varying  from  the  sixteenth 
to  the  eighth  of  a  grain,  three  times  in  the  tw^enty-four  houi-s, 
or  in  the  form  of  the  tincture,  of  which  five  to  eight  drops  may 
be  given  at  the  same  intervals.  I  have  met  with  several  rebel- 
lious ciises  in  boys  in  which  a  permanent  cure  was  effected  by 
the  daily  hypodermic  use  of  ten  drops  of  the  tincture.  A  stead}" 
persistence  of  the  treatment  for  several  months  is  necessary  to 
insure  a  cure;  and  the  effects  of  the  remedy  should  be  closely 
watched. 

Sometimes  great  benefit  results  from  the  use  of  anodyne 
enemata  and  suppositories  in  this  form  of  incontinence.  They 
almost  always  afford  temporary  amelioration,  but  occasionally 
they  promptly  remove  the  disease  after  a  failure  of  the  more 
common  means.  Suppositories  are,  on  the  whole,  more  effica- 
cious than  injections,  and  they  are  also  more  liable  to  be 
retained;  they  therefore  merit  a  decided  preference. 

The  application  of  pressure  to  the  urethra,  gentle  but  steady, 
and  gradually  increased,  has  sometimes  been  found  beneficial  in 
removing  this  complaint,  when  it  depends  upon  morbid  sensi- 
bility of  the  urethra  and  neck  of  the  bladder,  especially  where 
the  more  ordinary  means  have  failed.  When  the  tender  surface 
is  situated   behind    the   scrotum,   the   probability  is  that    the 


INCONTIXEXCE     OF    URINE.  103 

pressure  of  a  truss,  restiuo-  upon  the  perineum,  might  he  service- 
able. The  pad  should  be  [)laced  directly  over  the  middle  line, 
and  should  bear  so  firmly  upon  the  parts  as  to  occlude  the 
urethra.  A  far  better  mode  of  opposiiio-  an  obstacle  to  the  flow 
of  urine,  however,  is  that  devised  b}-  Dr.  Corrigan,  of  Dublin. 
The  preputial  orifice  is  closed  with  collodion,  Avhich  is  easily 
removed  with  the  finger-nail  on  the  following  morning,  or  when- 
ever the  child  desires  to  empty  his  Idadder. 

In  all  cases  of  nocturnal  i-ncontinence,  the  practitioner  must 
endeavor  to  secure  the  cooperation  of  the  patient.  The  unhappy 
ett'ects  arising  from  a  persistence  of  the  habit  must  be  fully 
pointed  out;  the  child  must  be  reasoned  with,  and  even  threat- 
ened with  chastisement;  the  fear  of  punishment  puts  him  on 
the  alert,  and  induces  him  to  keep  a  constant  watch  over  the 
bladder.  The  patient,  of  course,  is  not  beaten;  nor  does  any 
sensible  man  ever  think,  at  the  present  da}^  of  tying  up  the 
penis;  such  a  proceeding  would  be  not  less  cruel  than  absurd. 

I-  Organic  changes  of  the  prostate  may  occasionally  give  rise  to 
true  enuresis.  In  that  form  of  general  hypertrophy  of  the  gland, 
in  which  the  median  portion  acts  like  a  wedge,  and  separates 
the  lateral  lobes,  the  neck  of  the  bladder  is  kept  open,  and  the 
urine  constantly  trickles  away.  A  similar  efi'ect  is  produced  by 
senile  atrophy  of  the  organ,  an  entirel}-  opjjosite  condition,  with 
associated  atrophy  of  the  sphincter  of  the  bladder,  through 
which  there  is  no  natural  barrier  to  the  free  escape  of  the  urine. 
The  only  relief  in  such  cases  is  a  urinal. 

C  Incontinence,  like  retention  of  urine,  is  occasionally  of  a 
periodical  nature,  resembling,  in  this  res[)ect,  an  attack  of  inter- 
mittent fever,  only. that  it  is  not  preceded  by  chills,  or  followed 
by  sAveats.  One  of  the  best  marked  examples  of  this  variety  of 
the  afiection  of  which  I  have  any  knowledge,  came  under  my 
observation,  in  a  young  man,  twenty-two  years  of  age,  a  bar- 
keeper in  a  coftee-house,  of  sanguine  temperament,  and  perfectly 
regular  habits.  After  having  retired  one  evening,  in  his  usual 
health,  he  was  seized,  while  asleep,  with  a  discharge  of  urine, 
which  caused  him  to  wet  his  bed,  and  which  returned  after- 
wards, with  great  regularity,  every  night,  from  one  to  three 
o'clock.  The  discharge  occurred  sometimes  once,  sometimes 
twice,  and  occasionally  even  thrice,  during  the  night,  waking 
hira  generally  each  time.     In  the  day  lie  never  had  any  difl^- 


104  INCOXTIXEXCE    OF    UEINE. 

cult}^,  either  in  the  recumbent  or  the  erect  posture.  The  urine 
appeared  to  be  normal  both  in  quantity  and  qualit}'.  The  affec- 
tion had  existed  for  a  fortnight,  when  he  applied  to  me  for  relief. 
He  had  never  suffered  in  this  way  before,  and  he  could  assign  no 
reason  for  the  present  attack.  His  general  health  had  all  along 
been  good,  with  the  exception  of  slight  derangement  of  the 
digestive  organs;  the  appetite  was  excellent,  and  the  bowels 
were  perfectly  regular.  He  was  entirely  free  from  pain,  but 
complained  occasionally  of  a  sense  of  weight  and  uneasiness  at 
the  neck  of  the  bladder. 

As  his  tongue  was  quite  clean,  I  requested  him  merely  to 
regulate  his  diet,  to  avoid  all  stimulating  articles  of  food,  and 
to  take,  every  eight  hours,  seven  grains  of  quinia,  in  union  with 
the  eighth  of  a  grain  of  sulphate  of  morphia.  He  came  hack 
to  me  in  four  days,  declaring  that  he  was  perfectly  relieved,  and 
that  he  had  not  had  an  attack  of  his  complaint  since  his  first 
visit.  To  guard  against  relapse,  he  was  directed  to  continue 
the  treatment  for  several  days  longer,  when 
"■  ^^'  ^'-'  ^'^-  he  again  reported  himself  well,  nor  did  he 
have  any  other  attack  afterwards. 

A  very  instructive  case  of  this  form  of 

i^m         incontinence,  associated  with  inflammation 
W  of  the  neck  of  the  bladder,  and  unequivo- 

^L        cr\\\  dependent  upon  a  miasmatic  cause, 
WM        and  relieved  by  quinia,  is  related  by  Dr.  Wil- 
^m        liam  M.  Boling,  in  the  American  Journal 
H        of  the  Medical  Sciences,  for  July,  1844. 
H  Finally,  when  the  incontinence  is  irre- 

■  mediable,  the  patient  should  wear  a  urinal, 
I  to  prevent  the  fluid  from  soiling  his  clothes. 
I  The  best  contrivance  for  this  purpose  is  a 
I  gum-elastic  bag,  adapted  to  the  genitals 
I  and  the  inside  of  the  leg,  and  provided  with 
Female  Urinal.  Male  riinai.  ^  metallic  Cap  at  its  lowcr  extremity  for 
the  purpose  of  evacuating  the  urine.  The 
subjoined  cuts  will  convey  a  better  idea  of  the  apparatus  than 
any  descrii»tion,  liowever  elaborate.  Fig.  11  represents  the 
female,  and  fig.  12  the  male  urinal.  It  should  be  frequently 
washed  for  the  sake  of  cleanliness,  and  every  patient  should 
be  provided  with  an  extra  vessel,  so  that  he  may  not  sufter  any 
inconvenience  in  case  of  accident. 


CHAPTER    V. 

RETENTION  OF  URINE. 
Sect.  L— SYMPTOMS,  CAUSES,  AND  TREATMENT. 

The  symptoms  of  retention  of  urine  are  generally  well  marked, 
even  at  an  early  stage  of  the  complaint.  In  this  respect,  how- 
ever, there  is,  as  might  he  supposed,  considerahle  diversity  in 
dift'erent  cases,  depending  mainly  upon  the  natural  tolerance  of 
the  hladder,  and  the  character  of  the  exciting  cause  of  the  dis- 
ease. In  paralysis  of  the  muscular  fibres  of  the  organ,  attended 
with  loss  of  sensation,  the  accumulation  may  make  great  pro- 
gress, and  yet  the  individual  not  be  aware  of  his  real  condition. 
A  slight  discharge  of  urine,  perhaps,  occasionally  takes  place ; 
or  if,  as  often  happens,  incontinence  is  soon  superadded  to  the 
original  disorder,  the  fluid  dribbles  off  incessantly,  and  tlms  botH 
patient  and  physician  are  lulled  into  a  false  security.  When,  on 
the  contrary,  the  retention  is  inflammatorj^,  more  or  less  pain, 
and  frequent  inclination  to  void  the  urine,  with  inability  to  do 
so,  attend  the  complaint,  and  at  once  expose  its  true  character. 
In  all  cases,  where  suspicion  points  to  the  disease,  a  careful 
examination  of  the  hypogastric  region  should  be  instituted, 
aided,  if  there  be  any  obscurity,  by  the  finger  in  the  rectum  or 
the  vagina. 

The  tumor  in  the  hypogastrium,  formed  by  the  distended 
bladder,  fluctuates  distinctly,  especially  when  the  retention  is 
caused  b}'  paralysis ;  it  is  tender  on  pressure  and  percussion,  and 
is  not  aflected  by  change  of  posture.  In  old,  thin  persons,  it 
may  be  the  seat  of  transmitted  pulsations,  as  in  a  case  recorded 
by  Mr.  Druitt.'  Pain  frequently  exists  at  a  very  early  stage,  and 
steadily  inci^eases  until,  in  many  instances,  it  becomes  agonizing. 
1)1  protracted  cases,  more  especially  in  the  inflammatory  form  of 
the  afl'ection,  it  is  often  accompanied  with  forcing,  straining,  or 
tenesmus   at   every   attempt   at    micturition,  and  with    rigors 

'  Cooper's  Dictiomiry  of  Practical  k:hirger3',  8tli  ed.,  1861,  vol.  i.  p.  4. 


106  EETEXTIOX    OF    URIXE. 

{iltornating  with  flushes  of  heat,  thirst,  and  excessive  restlessness ; 
tlie  patient  tossing  about  in  the  wildest  and  most  frightful 
manner.  In  the  mean  time,  there  is  an  urgent  desire  to  void 
the  urine,  which  is  either  not  passed  at  all,  or  is  discharged  in 
gushes,  jets,  or  drops,  not  in  a  full  stream,  or  in  any  considerable 
quantit}'  at  a  time.  Tliis  symptom  often  sets  in  at  an  early 
stage  of  the  complaint,  and  is  apt  to  lead  the  unwary  into  error, 
by  inducing  the  belief  that  the  case  is  one  of  mere  incontinence 
instead  of  retention.  Such  a  mistake,  unfortunately  not  un- 
common, is  often  fatal  to  the  poor  sufferer ;  the  proper  means  of 
relief  are  neglected,  the  accumulation  progresses,  and  the  bladder, 
distended  to  its  utmost  power  of  endurance,  either  mortifies  or 
bursts ;  or  death  ensues  from  uremia.  The  fatal  event,  however 
induced,  is  generally  preceded  by  a  typhoid  state  of  the  system  ; 
a  small,  shattered  pulse ;  cold,  clammy  sweats;  pale  and  shrunken 
features;  hiccup  and  twitching  of  the  tendons;  nausea, extreme 
restlessness,  urinous  perspiration,  and  profound  coma. 

During  the  [)rogress  of  the  retention,  the  distended  bladder, 
by  pressing  on  the  rectum,  impedes  the  exit  of  the  feces,  and 
leads  to  pain  and  fulness  of  the  bowels.  From  the  same  cause, 
there  is  sometimes  partial  prolapse  of  the  vagina,  and,  in  both 
sexes,  even  of  the  rectum.  AVhen  the  tumor  has  reached  its 
maximum  development,  it  pushes  up  the  diaphragm,  and  sensibly 
embarrasses  the  respiratory  functions.  The  coats  of  tlie  bladder, 
in  the  more  severe  forms  of  the  aftection,  are  attenuated,  and, 
owing  to  the  constant  pressure  which  they  experience,  ultimately 
inflame,  and  are  ready  to  give  way  under  the  accumulated 
sufl:ering.  In  those  who  die,  softened,  ulcerated,  or  gangrenous 
patches  are  often  observed ;  the  orifices  of  the  ureters  are  forced 
apart;  and  the  urine,  highly  vitiated  and  ofl:ensive,  fails  to 
descend  from  the  kidneys,  or  ceases  to  be  secreted. 

The  period  at  which  death  occurs  in  this  afl'ection  varies  in 
diflerent  cases  and  under  dift'erent  circumstances.  Most  patients, 
if  not  relieved,  perish  in  five  or  six  days;  a  few  before  that  time, 
and  a  few  not  until  later.  The  immediate  cause  of  death  may 
be  rupture  of  the  bladder,  with  effusion  of  urine  into  the  perito- 
neal cavity  ;  exhaustion  from  mortification  of  the  coats  of  the 
organ  ;  or  uremic  poisoning. 

When  its  mode  of  origin,  its  progress,  and  its  symptoms,  which 
are  usually  sufficiently  characteristic,  are  considered,  it  is  difii- 


SYMPTOMS,    CAUSES,    AND    TREATMENT.  107 

cult  to  conceive  how  retention  of  urine  could  ever  be  mistaken 
for  any  other  complaint.  Yet,  strange  as  it  may  appear,  some 
very  singular,  as  well  as  very  unfortunate,  blunders  have  occa- 
sionall}^  been  committed  in  this  respect,  and  that  too  by  men 
who,  from  their  skill  and  experience,  ought  to  have  known 
better.  The  affection  with  whicli  it  is  most  liable  to  be  con- 
founded is  ascites,  or  dropsy  of  the  peritoneal  cavity,  and  tapping- 
has  been  advised,  or  actually  performed,  for  its  relief. 

In  ascites,  the  abdominal  tumor  isdifl:iised,not  circumscribed, 
and  changes  its  form  and  situation  with  the  position  of  the  bod}' ; 
there  is  little,  if  any,  tenderness  on  pressure  and  percussion  ;  the 
sense  of  fluctuation  is  more  distinct ;  the  progress  of  the  disease 
is  more  tardy ;  the  urine,  although  more  scanty  than  in  health, 
is  voided  several  times  in  the  twenty-four  hours,  generally  with- 
out pain  or  ditKculty  ;  there  is  commonly  anasarca  of  the  lower 
extremities ;  the  skin  is  dry  and  harsh  ;  and  there  is  usually  an 
absence  of  febrile  disturbance,  and  always  of  typhomania  and 
urinous  odor.  If  any  doubt  exist,  the  introduction  of  the  cathe- 
ter will  at  once  dispel  it. 

In  advanced  pregnancy,  a  trocar  has  been  thrust  across  both 
walls  of  the  bladder  into  the  child's  head,  under  the  supposition 
that  the  disease  was  ascites.  A  distended  bladder  has  also  been 
mistaken  for  ovarian  dropsj^ ;  and,  on  the  other  hand,  dropsy 
has  sometimes  been  mistaken  for  retention  of  urine.  The  elder 
Berard  relates  a  case  of  the  kind.  The  patient  was  supposed  to 
be  laboring  under  distention  of  the  bladder;  the  catheter,  as 
was  conjectured,  came  in  contact  with  a  stricture,  and  was 
pushed  on  with  so  much  violence  as  to  pierce  the  bladder,  fol- 
lowed by  an  escape  of  the  ascitic  fluid.  The  patient  died,  and 
the  fact  here  stated  was  verified  by  the  dissection  of  the  body.' 

A  distended  bladder  may  be  mistaken  for  a  suprapubic  abscess. 
Two  such  cases  came  under  the  observation  of  Colot ;-  and  other 
examples  of  a  similar  nature  have  been  reported  by  more  recent 
writers.  An  error  of  an  opposite  character  occasionally  occurs, 
a  pelvic  abscess  being  mistaken  for  a  distended  bladder,  as  hap- 
pened  to  Dr.   George  McClellan^  and   Dr.  Physick.     A  large, 

'  A.  Berard,  Diagnostique  Chiriirgicale,  1830,  p.  123. 

2  Belmas,  Traite  de  la  Cystotomie  Suspubienue,  p.  63. 

3  Principles  and  Practice  of  Surgerj-,  Pliila.  1848,  p.  13o. 


108  RETENriOX    OF    URINE. 

fluctuating  tumor  existed  in  the  hypogastric  region,  which  felt 
and  looked  precisely  like  an  overdistended  bladder,  and  was 
attended  with  all  the  symptoms  of  retention.  The  introduction 
of  the  catheter  was  followed,  however,  by  only  about  half  an 
ounce  of  urine.  The  finger,  inserted  into  the  rectum,  came  in 
contact  with  an  apparently'  enormous  enlargement  of  the  base 
of  the  bladder,  and  fluctuation  was  elicited  by  counter-pressure 
above  the  pubes.  The  catheter  was  used  again  and  again,  with 
no  better  eftect  than  in  the  first  attempt.  During  the  last 
operation,  blood  appeared  in  the  eyes  of  the  instrument,  and  the 
patient  felt  conscious,  during  its  passage,  that  something  had 
been  torn.  Finally,  a  trocar  was  plunged  into  the  supposed 
vesical  tumor  above  the  pubes,  and,  to  the  astonishment  of  both 
surgeons,  a  large  quantity  of  sero-purulent  fluid  escaped  instead 
of  urine.  The  man  died  in  a  few  hours  after  the  operation,  and 
the  dissection  revealed  the  existence  of  a  large  abscess,  which 
had  evidently  been  caused  by  the  lodgment  of  a  date-stone, 
swallowed  two  years  previously,  in  the  vermiform  process,  and 
the  contents  of  which  had  partially  surrounded  the  bladder, 
extending  uf)wards  into  the  hypogastric  region,  and  downwards 
into  the  pelvic  cavity,  where  it  compressed  the  rectum,  and  was 
mistaken  for  a  distention  of  the  fundus  of  the  urinary  reservoir. 
It  appeared  that  the  catheter,  during  its  last  introduction  by 
Dr.  Physick,  had  entered  the  orifice  of  the  right  ureter,  the 
mucous  lining  of  which  was  torn  to  a  considerable  extent,  and 
elevated  by  the  infiltration  of  the  subjacent  connective  tissue, 
thus  puffing  up  the  parts  like  a  blister. 

A  curious  ease  of  pericystic  accumulation  of  fat,  which  formed 
a  tumor  in  the  hypogastrium,  simulating  in  location,  outline, 
and  feel,  a  distended  bladder,  and  giving  rise  to  retention  in  a 
man,  eighty-two  years  of  age,  has  been  recorded  by  Dr.  Smith,^ 
of  Pittsfield.  The  organ  was  surrounded  by  an  enormous  mass 
of  fat,  by  which  it  had  been  folded  upon  itself,  through  retro- 
flexion of  its  fundus,  so  as  practically  to  consist  of  two  cavities, 
the  upper  of  which  contained  twelve  ounces  of  fluid.  During 
life  the  catheter  could  not  be  moved  freely  in  the  lower  cavity, 
nor  could  its  beak  be  carried  to  the  bas-fond  of  the  bladder. 
Only  a  little  bloody  urine  was  withdrawn. 

'  Boston  Med.  and  Surg.  Journal,  July  18,  18G7,  p.  496. 


SYMPTOMS,    CAUSES,   AND    TREATMENT.  109 

The  treatment  of  retention  of  urine  is,  in  the  first  instance, 
by  the  catheter  ;  since  the  indication  is  to  relieve  the  organ 
with  the  least  possible  delay,  before  the  part  and  the  system 
have  sustained  serious  mischief.  When  there  is  great  distention, 
amounting  to  several  quarts,  it  is  best  and  safest,  as  a  general 
rule,  not  to  empty  the  bladder  at  a  single  operation,  but  gradu- 
ally, drawing  otf  a  portion  of  its  contents  now,  and  another  by 
and  by.  The  catheter  is  introduced,  and  half  the  fluid  is  eva- 
cuated, to  aftbrd  the  overstretched  fibres  an  opportunity  of  con- 
tracting and  regaining  their  power.  Some  hours  afterwards  the 
instrument  is  again  used,  and  the  remainder  of  the  urine  is 
withdrawn!.  Under  this  practice,  there  is  less  risk  of  inflamma- 
tion of  the  bladder  and  of  general  exhaustion.  Where  this  pre- 
caution is  neglected,  the  abdomen  should  be  supported  with  a 
compress  and  a  broad  roller,  as  after  tapping  and  parturition. 
A  point  of  the  last  importance  is  not  to  relieve  the  bladder 
when  the  patient,  especially  if  he  is  old  or  infirm,  is  in  the  erect 
})Osture.  From  a  want  of  attention  to  this  precaution,  death 
from  sudden  syncope  has  been  known  to  occur.  A  large  opiate 
should  also  be  exhibited  just  before,  or  immediately  after,  the 
operation,  premising,  of  course,  that  there  is  no  contraindication 
on  account  of  cerebral  oppression. 

Retention  of  urine  may  be  produced,  first,  by  mechanical  and 
pathological  obstruction  ;  secondly,  by  paralysis ;  thirdly,  by 
spasm ;  fourthly,  by  inflammation  ;  fifthly,  by  pelvic  tumors  ; 
sixthly,  by  certain  conditions  of  the  uterus  and  female  genital 
organs ;  seventhly,  by  distention  of  the  rectum ;  eighthly,  by 
hysteria  and  deficient  volition ;  and,  ninthly,  by  the  effects  of 
miasm. 

1.  The  first  class  of  causes  may  affect  the  penis  and  prepuce, 
the  urethra,  or  the  bladder. 

a.  Retention  of  urine  may  depend  upon  priapism,  induced  by 
inflammation,  and  the  consequent  effusion  of  lymph  in  the 
cavernous  bodies,  by  lesion  of  the  cerebro-spinal  axis,  or  by  the 
injudicious  use  of  cantharides.  For  its  relief,  recourse  is  at  once 
had  to  the  catheter,  attention  being  afterwards  paid  to  the 
removal  of  the  exciting  cause. 

The  obstruction  may  be  occasioned  by  an  imperforate  prepuce. 
Many  years  ago  I  met  with  an  instance  of  this  kind,  in  an  infant 
two  days  old,  in  which  the  foreskin  was  distended  into  a  pellucid, 


110  RETENTIOX    OF    UEINE. 

fluctuiiting  tumor,  nearly  as  large  as  a  pullet's  egg.  The  little 
patient  was  in  great  pain,  but  was  instantly  relieved  by  a  free 
incision,  which  was  followed  by  at  least  four  ounces  of  urine. 

ft.  The  urethra  may  be  obstructed  by  congenital  occlusion,  a 
polypoid  or  papillary  growth,  a  calculus,  clotted  blood,  false 
membrane,  inspissated  mucus,  periurethral  deposits  and  lesions, 
organic  stricture,  and  hypertrophy,  or  other  diseased  conditions 
of  the  prostate  gland.  A  catheter,  bougie,  or  other  foreign  body 
may  break  off  in  the  canal,  and  thus  become  an  impediment  to 
the  egress  of  the  urine. 

Retention  occasioned  by  congenital  occlusion  is  almost  always 
easily  remedied  by  the  knife  and  catheter,  the  use  of  which 
should  be  continued  until  the  parts  are  fully  cicatrized,  lest 
they  should  reunite,  and  thus  occasion  a  recurrence  of  the 
difficulty.  Tumors  are  removed  by  excision,  avulsion,  or  caustic 
applications.  An  impacted  calculus  may  generally  be  pushed 
back  into  the  bladder,  or  extracted  with  the  forceps;  or,  when 
these  means  fail,  l)e  removed  by  external  incision.  Pieces  of 
bougie  or  catheter,  or  other  foreign  bodies,  are  managed  upon 
the  same  principles.  Clotted  blood,  false  membrane,  and  inspis- 
sated mucus  are  easily  displaced  by  the  catheter,  or  dislodged  by 
the  syringe,  or  forced  out  by  the  urine. 

The  obstacle  may  lie  exterior  to  the  urethra,  and  the  conse- 
quences be  the  same  as  when  it  exists  internally,  as  is  witnessed 
in  abscess  of  the  perineum,  deep-seated  collections  of  blood,  an 
effusion  of  lymph,  or  a  malignant  tumor.  Carcinoma  of  the 
penis,  in  its  progress  towards  the  bladder,  contusions  of  the 
perineum,  and  extravasation  of  urine  are  frequently  followed  by 
the  worst  forms  of  retention. 

When  the  obstruction  is  seated  externally,  and  bulges  inwards, 
so  as  to  occlude  the  canal,  the  knife  supersedes  the  catheter,  the 
use  of  which  would  be  productive  of  much  pain,  especially  in  a 
perineal  abscess.  The  parts  are  Ireely  divided  from  without ; 
the  swelling  is  instantly  removed,  and  the  urine  is  enabled  to 
floAV  along  the  natural  channel.  When  the  obstruction  is  pro- 
duced by  extravasated  blood,  in  consequence  of  a  fall  or  kick, 
its  absorption  is  promoted  by  the  application  of  acetate  of  lead, 
hydrochlorate  of  ammonia,  or  spiritous  embrocations.  In  reten- 
tion from  malignant  disease  of  the  penis,  the  bladder  is  relieved 
by  puncture.     In  contusions  of  the  perineum  without  rupture  of 


SYMPTOMS,    CAUSES,   AND    TREATMENT. 


Ill 


Fin;.  13. 


the  urethra,  the  catheter  is  used  ;  but  when  the  accident  is  at- 
tended by  laceration,  a  large  incision  is  made,  to  save  the  tissues 
from  urinary  infiltration. 

In  organic  stricture,  relief  is  generally  obtained  by  canying  a 
silver  catheter  down  to  the  seat  of  the  obstruc- 
tion, when,  by  making  slow  and  steady  but  firm 
pressure,  the  impediment  is  overcome,  especially 
if  the  patient  be  under  the  influence  of  chloro- 
form. Should  the  passage  of  even  the  smallest 
sized  catheter  be  impracticable,  recourse  is  had 
to  the  probe-pointed,  filiform  whalebone  bougie, 
which  may  be  insinuated  through  the  coarcta- 
tion, when  the  tunnelled  catheter  of  Dr.  Gouley, 
shown  in  fig.  13,  may  be  passed  over  it  into 
the  bladder  and  the  urine  evacuated.  In  cases 
of  this  nature,  I  deem  it  advisable,  before  re- 
moving the  whalebone  guide,  to  use  it  as  a  con- 
ductor for  a  tunnelled  divulsor  or  urethrotome, 
through  which  the  stricture  may  be  s[)lit  or 
incised,  and  future  risks  be  obviated.  Should  the 
bladder  not  be  entered,  after  patient  trial  with 
instruments,  a  small  wax  bougie,  armed  with 
a  bit  of  potassa  fusa,  may  be  passed  down  to, 
and  firmly  pressed  against,  the  stricture.  In 
this  wa}^,  Mr.  Parker,^  of  Birmingham,  succeeded 
in  promptly  relieving  two  cases.  In  the  event 
of  the  failure  of  these  means,  the  only  resources 
are  perineal  urethrotomy,  aspiration,  or  puncture 
of  the  bladder,  which  are  described  at  the  end 
of  this  chapter,  or  tapping  the  membranous 
urethra  behind  the  seat  of  the  obstruction. 
This  operation,  wdiicli  is  as  simple  as  it  is 
eftectual,  was  first  practised  by  Mr.  Molins,  of 
London,  in  1652,  and  is  especially  adapted  to  cases  of  retention 
from  impassable  stricture  seated  in  front  of  the  curved  urethra. 
The  patient  being  placed  in  the  lithotomy  position,  and  the  tip 
of  the  left  index-finger  being  lodged  at  the  apex  of  tlje  prostate 
gland,  with  the  anterior  wall  of  the  rectum  intervening,  as  re- 
presented in  fig.  14,  from  Bryant,  a  straight  or  slightly  curved 


Gouley's    Tnunelled 
Catheler. 


'  British  Medical  Journal,  May  2,  IS.'.O,  p.  400. 


112 


EETENTION    OF    URIXE. 


bistoury,  with  its  back  directed  towards  the  bowel,  is  entered 
at  the  median  raphd,  five  lines  in  front  of  the  anus,  and  pushed 
steadily  upwards,  as  if  to  strike  the  pulp  of  the  finger,  which 


Fig.  14. 


Tapping  llie  Uietlira  in  the  Perineum. ' 

serves  to  guide  it  into  the  membranous  urethra,  which  is  then 
opened,  along  with  the  apex  of  the  prostate,  as  the  knife  is 
withdrawn,  when  the  external  wound  is  simultaneously  en- 
larged. The  subsequent  retention  of  a  canula  in  the  bladder 
is  entirely  unnecessary. 

The  most  common  form  of  obstruction  of  the  urethra  and  neck 
of  the  bladder,  productive  of  retention  of  urine,  is  hypertrophy 
of  the  prostate  gland.  The  enlargement  may  involve  the  entire 
organ,  or  it  may  be  limited  to  one  of  its  lateral  lobes,  or  even  to 
its  median  portion.  In  most  cases,  all  these  parts  are  aft'ected 
simultaneously,  though  not  to  the  same  extent.  A  very  dis- 
tressing and  intractable  form  of  retention  of  urine  is  occasionally 
produced  by  the  median  portion,  or,  as  it  is  more  commonly 
called,  the  third  lobe  of  the  prostate,  which  is  often  many  times 
larger  than  in  the  healthy  state,  constituting  a  thick,  mammil- 
lated  body,  which  closes  the  vesical  orifice  of  the  urethra  like  a 
valve.  Whatever  may  be  the  form  of  enlargement,  it  is  usually 
attended  with  certain  alterations  in  the  sliape,  size,  and  direction 
of  the  prostatic  urethra,  which  may  be  narrowed,  greatly 
lengthened,  deflected  to  one  side  or  the  other,  tortuous,  curved 
directly  upwards,  or  form  a  more  or  less  decided  angle.  These 
deviations  from  the  normal  condition  serve  to  explain  the  difii- 
culties  encountered  in  the  passage  of  the  ordinary  catheter. 


SYMPTOMS,    CAUSES,    AND    TREATMENT.  113 

Retention  of  urine,  dependent  upon  enlargement  of  tlie  pros- 
tate, is  usually  of  a  temporarj^  character,  but  is  liable  to  be  repro- 
duced by  the  slightest  exposure  to  cold,  by  irregularity  of  diet, 
by  horseback  exercise,  sexual  indulgence,  or  neglect  to  empty 
the  bladder.  During  the  attack,  as  well  as  for  some  time  after, 
the  urine  is  loaded  with  thick,  tenacious  mucus,  and  exhales  an 
offensive  ammoniacal  odor,  the  calls  to  micturition  are  frequent 
and  urgent,  there  is  scalding  in  the  urethra,  with  a  sense  of 
weight  or  throbbing  in  the  perineum,  and  the  patient  often 
suffers  indescribable  torments.  In  protracted  cases,  the  retention 
is  apt  to  be  attended  with  incontinence,  and  the  organ  is  rarely 
entirely  emptied  without  instrumental  aid. 

The  treatment  is  by  the  catheter ;  and  one  of  silver  is  far  pre- 
ferable to  the  flexible  English  instrument,  especially  when  the 
gland  is  greatly  enlarged.  It  should  be  at  least  twelve  inclies  in 
length  from  the  beak  .to  its  rings,  and  its  curve  should  form  an 
arc  equal  to  one-third  of  the  circumference  of  a  circle  five  inches 
and  a  half  in  diameter.  When  it  comes  in  contact  with  the 
enlarged  gland,  instead  of  forcing  it  onward,  the  surgeon  intro- 
duces the  left  index-finger  into  the  rectum,  and  placing  it  against 
the  beak,  he  guides  it  into  the  bladder,  by  tilting  it  gently 
towards  one  side  or  upwards  towards  the  pubes,  at  the  same 
time  that  he  urges  the  handle  on  with  the  right  hand.  In  very 
old  men,  with  inordinate  hypertrophy  of  the  gland  and  great 
lengthening  of  the  included  urethra,  the  silver  instrument  may 
be  advantageously  replaced  by  a  flexible  catheter,  from  twelve 
to  fifteen  inches  in  length,  which  has  been  kept  on  an  over- 
curved  stylet,  as  represented  in  fig.  15,  so  as  to  insure  a  good 
curve  to  the  beak,  whereby  it  is  enabled  to  pass  the  more 
readily  over  the  obstruction.  The  soft,  elastic,  angular  catheter 
of  Mercier,  represented  in  fig.  16,  is  invaluable  when  the 
urethra  forms  an  angle  in  consequence  of  enlargement  of  the 
middle  lobe ;  and  it  is  well  adapted  to  cases  in  which  fiilse  pas- 
sages have  been  made,  since,  during  its  introduction,  the  beak  is 
always  in  contact  with  the  roof  of  the  urethra.  When  the 
canal  is  deflected  to  one  side,  the  soft,  pliable  French  instru- 
ments, represented  in  figs.  17,  18,  will  often  follow  the  changed 
relations  of  the  canal,  when  stiff  catheters  fail.  The  vulcanized 
India-rubber  catheter,  unprovided  with  a  bulbous  end,  is  intro- 


114 


EETEXTION    OF    URINE. 


duced  by  a  succession  of  short  jerks.     These  instruments  are 
invaluable  in  the  treatment  of  prostatic  hypertrophy,  and  no 


Fisr.  15. 


Fig  16. 


Fig.  17. 


Fisr.  18. 


1 


Over-curved  Flexible  Catln-ter.        Mercier's  Catheter. 


French  Gum-elastic  Catheteis. 


surgeon  should  be  without  them.  Dr.  Squire,  of  Elmira,  has 
devised  a  vertebrated  catheter,  the  vesical  extremity  of  which 
is  composed  of  a  series  of  caps,  united  by  a  linked  wire,  an 
arrangement  which  admits  of  its  easy  introduction  and  the 
removal  of  the  residual  urine  which  is  dammed  in  by  the  en- 
larged prostate. 

To  fulfil  the  same  indications,  Dr.  S.  W.  Gross  employs  the 
silver  instrument,  represented  in  fig.  19.  The  beak,  which  is 
three-fourths  of  an  inch  in  length,  and  bent  at  an  angle  of  100°, 
through  which  it  resembles  the  catheter  of  Mercier,  is  united  to 
the  shaft  by  means  of  a  closely  wound  coil  of  silver  wire,  a  mode 


SYMPTOMS,    CAUSES,    AXD    TREATMEXT.  115 

of  imparting  flexibility  to  metallic  instruments,  for  wliieh  the 
profession  is  indebted  to  Dr.  R.  J.  Levis,  of  this  city.     After 

Fis.  19. 


Prostatic  Cstlieter 


passing  the  obstruction,  b}^  reversing  the  beak,  the  residual 
urine  readily  drains  away.  The  fault  of  catheters  of  large 
curve  is  their  inability  to  reach  the  cavity  behind  the  enlarged 
gland. 

Should  it  be  impossible  to  relieve  the  retention  with  the  cathe- 
ter, other  measures  will  have  to  be  resorted  to ;  but  as  these  are 
discussed  in  the  chapter  on  Hypertrophy  of  the  Prostate,  it  is 
unnecessary  to  describe  them  at  this  time. 

When  the  enlargement  of  the  prostate  is  associated  with 
inflammatory  symptoms,  as  it  occasionally  is  wdien  it  is  depend- 
ent upon  engorgement  rather  than  upon  true  hypertrophy,  the 
treatment  is  by  antiphlogistics,  such  as  bleeding,  leeching,  anti- 
monials,  the  hot  hip-bath,  and  anodyne  enemata.  Undue  dis- 
tention is  relieved  by  the  bulbed  soft  catheter,  of  the  calibre  of 
8  or  10  of  the  French  scale.  In  retention  from  abscess,  when  the 
swelling  projects  into  the  urethra,  a  conical  silver  instrument  is 
preferable,  as  it  not  only  admits  of  opening  the  collection  of 
pus,  but  of  the  evacuation  of  the  urine. 

7.  In  the  third  place,  the  obstruction  may  be  seated  in  the 
l)ladder.  Of  this  class  of  causes  the  most  frequent  are,  coagu- 
lated blood,  calculous  concretions,  false  membranes,  tenacious 
mucus,  and  neoplasms. 

Retention  from  coagulated  blood  is  often  a  very  serious  affair, 
since  the  fluid,  however  furnished,  soon  coagulates,  and  thus 
oft'ers  a  barrier  to  the  escape  of  urine.  Its  presence  may  be 
suspected  if,  in  the  absence  of  previous  urinary  disease,  retention 
follows  contusion  of  the  perineum  or  hypogastrium,  and  the 
withdrawal  of  the  catheter  is  attended  by  the  flow^  of  a  few 
drops.  It  sometimes  complicates  the  existence  of  highly  vascu- 
lar morbid  grow^ths,  when  its  diagnosis  is  easy.  Unless  the 
symptoms  are  urgent,  nothing  need  be  done  save  to  relieve  the 


116  EETEXTIOX    OF    URIXE. 

frequent  desire  to  urinate  by  full  doses  of  opium.  "When  the 
effusion  is  recent,  the  introduction  of  an  instrument  can  do  no 
good,  since  its  eyes  become  plugged  by  the  blood,  thereby  pre- 
venting the  passage  of  the  urine.  The  beneficial  eflfects  of  delay, 
under  such  circumstances,  are  often  very  striking.  In  an  old 
gentleman,  seventy-two  years  of  age,  whom  I  saw  some  years 
ago  with  Dr.  Pirtle,  the  distended  bladder  formed  a  large  tumor 
above  the  pubes,  but  not  a  drop  of  urine  followed  the  use  of  the 
catheter.  Eighteen  hours  subsequently,  almost  a  quart  of  nearly 
clear  fluid  was  drawn  oflf.  The  blood  had,  in  the  interval, 
evidently  subsided  to  the  bottom  of  the  bladder,  and  thus 
allowed  the  urine  to  act  the  part  of  a  supernatant  fluid. 

When  the  hemorrhage  is  due  to  regurgitation  from  injury 
inflicted  upon  the  posterior  portion  of  the  urethra  by  the  intro- 
duction of  instruments,  or  other  traumatic  causes,  evacuation 
should  be  attempted  with  a  large  silver  catheter,  the  orifice  of 
which  is  completely  occluded  with  an  obturator  attached  to  a 
stylet,  removed  the  moment  the  instrument  reaches  the  bladder. 
Such  an  instrument,  which  I  had  constructed  many  years  ago, 
and  which  I  have  often  used  with  an  admirable  effect,  is  repre- 
sented in  fig.  20. 

F\cr.  20. 


Blood  Catheter. 


In  some  cases,  the  bladder  may  be  distended  to  such  a  degree 
as  to  imperil  life  from  rupture  of  tlie  organ  or  suppression  of 
urine.  In  such  an  event,  the  clot  should  be  broken  down  by  a 
large  silver  catheter,  aided  by  injections  of  cold  water,  or,  what 
is  still  better,  water  and  vinegar,  and  an  exhausting  syringe,  or 
Clover's  evacuating  apparatus  for  lithotrity.  It  may  even  be 
necessary,  in  exceptional  instances,  to  resort  to  suprapubic  or 
perineal  cystotomy. 

Retention,  caused  by  calculous  concretions,  tumors,  ropy  mucus, 
or  false  membrane,  is,  in  general,  easily  relieved  by  the  catheter, 
and  does  not,  therefore,  require  special  consideration. 

II.  Retention  of  urine  from  atony  or  paralysis  of  the  muscular 


SYMPTOMS,    CAUSES,    AXD    TREATMEXT.  117 

fibres  of  the  bladder  is  of  common  occurrence;  but  as  its  causes 
and  treatment  have  ah-eadj^  been  pointed  out  in  Chapter  III.,  its 
consideration,  in  this  connection,  may  be  dismissed.  The  liabilit}' 
of  this  variety  of  retention,  liowever,  to  be  followed  by  inconti- 
nence cannot  be  too  forcibly  or  too  frequently  impressed  upon 
the  mind  of  the  practitioner. 

III.  Eetention  of  urine  from  spasm  of  the  neck  of  the  bladder, 
or  of  the  urethra,  constituting,  when  the  latter  locality  is  affected, 
spasmodic  stricture  of  the  urethra,  is  commonly  produced  by 
cold,  by  suppression  of  the  cutaneous  perspiration,  and  by  the 
use  of  alcoholic  drinks,  in  persons  suffering  from  slight  inflamma- 
tion of  the  curved  urethra.  The  remitting  pains,  the  violent 
straining,  and  the  frequent  desire  to  urinate,  clearly  indicate  the 
nature  of  the  complaint.  The  proper  treatment  is  indicated  at 
page  70.  When  it  is  due  to  reflected  irritation,  the  removal 
of  its  exciting  cause  suffices  for  a  cure. 

IV.  Retention  may  be  produced  by  inflammation  of  the  neck 
of  the  bladder,  or  of  this  organ  and  of  the  urethra,  when  it  is 
usually  associated  with  spasm.  The  S3'mptoms  are,  a  frequent 
desire  to  urinate,  with  an  inability  to  pass  more  than  a  few  drops 
of  water  at  a  time  ;  a  sense  of  smarting,  burning,  or  scalding,  in 
the  urethra  and  the  head  of  the  penis  ;  violent  straining  ;  a  feel- 
ing of  weight  about  the  anus;  and  throblnng  in  the  perineum. 
Occasionallj'  the  urine  is  mixed  with  blood  or  pus. 

The  treatment  is  antiphlogistic.  Perfect  recumbency  is  enjoined ; 
general  or  local  bloodletting  may  be  necessary ;  the  bowels  are 
moved  by  mild  laxatives;  the  patient  is  placed  in  a  w^arm  bath; 
and  spasm  is  allayed  by  anodyne  enemas  and  the  exhibition  of 
chloroform.  Wlien  the  symptoms  are  urgent,  and  the  means 
here  indicated  are  ineffectual,  a  soft  catheter  must  be  used,  but 
not  without  the  greatest  care  and  gentleness. 

Y.  Retention  of  urine  may,  in  the  fifth  place,  depend  upon 
the  presence  of  a  pelvic  tumor.  Of  this  class  of  causes,  several 
varieties  may  be  enumerated. 

a.  The  difficulty  may  arise  from  cysts  between  the  bladder 
and  the  rectum,  which  compress  the  neck  of  the  former  viscus. 
Instructive  examples  of  serous  c3-sts  have  been  furnished  by 
Lesauvage,  Spence,  and  Smith.  Hydatid  cysts  liave  been  met 
with  by  White,  Maunder,  Farre,  Spence,  Bryant,  Prieger,  and 
James;  and  a  cyst,  which  contained  two  pints  of  an  oily  fluid, 


118  RETEXTIOX    OF    UUIXE. 

has  been  reported  by  Pretty.  The  case  occurred  in  a  man, 
twenty-four  years  of  age,  and  the  peculiar  fluid  was  probably 
due  to  a  degenerated  congenital  dermoid  tumor.  In  all  of  these 
instances  a  swelling  was  felt  through  the  rectum  and  the  belly ; 
and  in  all,  save  one,  in  which  Mr.  Bryant  opened  the  cyst 
through  the  perineum,  relief  was  afforded  by  rectal  puncture. 

i3.  The  neck  of  the-  bladder  may  be  compressed  by  an  exos- 
tosis of  the  pelvic  bone,  whereby  it  is  rendered  unable  to  void 
its  contents.  In  an  example  of  this  description  Boyer  was 
unable  to  introduce  a  catheter. 

7.  Retention  may  arise  from  a  displaced  kidney.  Of  this 
occurrence,  a  remarkable  and  unique  instance  is  recorded  by  Pro- 
fessor Gouley.'  A  man,  twenty -four  years  of  age,  suffering  with 
symptoms  of  retention,  was  subjected  to  rectal  jDuncture,  after 
failure  with  the  catheter,  with  the  effect  of  the  escape  of  a  little 
urine.  Three  days  subsequently,  eight  ounces  of  fluid  were 
drawn  off  in  the  usual  way  ;  but  without  making  any  impression 
on  the  hypogastric  tumor,  which  felt  like  a  distended  bladder. 
On  death  from  peritonitis,  a  single  kidney,  the  pelvis  of  which 
was  enormously  dilated  and  filled  Avith  urine,  was  found  to 
occupy  the  pelvis  behind  the  bladder.  Xot  only  was  there  reten- 
tion of  urine  in  that  viscus,but  also  in  the  pelvis  of  the  kidne}^ 
the  latter  of  which  had  been  produced  by  compression  of  the 
short  ureter,  partly  by  the  kidney,  and  partly  by  the  bladder. 

VI.  Certain  conditions  of  the  uterus  and  of  the  female  genital 
organs  are  liable  to  be  attended  with  retention  of  urine.  In  the 
female,  retention  is  rarely  met  with  in  connection  with  affec- 
tions of  the  urinary  organs ;  but  is  generally  due  to  some  mecha- 
nical condition  of  the  pelvic  organs,  though  while  the  urethra  is 
compressed  against  the  subpubic  ligament,  or  materially  changed 
in  its  form  and  direction.  Of  the  causes  inherent  in  the  uterus 
the  most  common  and  important  are,  prolapse,  retroversion  or 
retroflexion,  tumors  in  its  walls  or  cavity,  and  hematometra. 
Among  the  periuterine  causes  may  be  mentioned  pelvic  hema- 
tocele, pelvic  abscess,  and  cellulitis,  pelvic  peritonitis,  and  tumors 
of  the  ovary,  broad  ligament,  and  Fallopian  tube.  Xeoplasms, 
abscesses,  and  prolapse  of  the  walls  of  the  vagina  ;  dependent 
uterine  polyps ;  retained  menses,  from  imperforate  hymen,  are 
so  many  causes  of  retention.     It  occasionally  takes  place  during 

'  Diseases  of  the  Urinaiy  Organs,  p.  235,  New  York,  1873. 


SYMPTOMS,    CAUSES,   AND    TREATMENT.  119 

uterogestation,  from  the  pressure  which  the  womb  exerts  upon 
the  bladder.  The  accident  is  liable  to  happen,  chiefl}',  either  a 
short  time  before  the  occurrence  of  quickening,  or  during  the 
last  three  months  of  pregnancy.  Distention  of  the  bladder  also 
sometimes  occurs  during  parturition,  when  it  is  particularly  to 
be  dreaded,  as  it  has  occasionally  been  followed  by  laceration  of 
its  coats,  and  the  escape  of  urine  into  the  peritoneal  cavity.  A 
full  bladder,  as  previously  mentioned,  may  also  be  a  cause  of 
postpartum  hemorrhage. 

The  treatment  of  retention  from  so  many  and  such  varied 
conditions  cannot,  of  course,  be  dwelt  upon.  Displacements 
must  be  remedied;  abscesses  and  collections  of  blood  be  evacu- 
ated ;  and  tumors  removed.  When  the  symptoms  are  urgent, 
the  catheter  must  be  employed.  In  many  cases,  the  common 
female  catheter  is  unavailing,  on  account  of  its  small  curve,  and 
the  impossibility  of  carrying  it  up  behind  the  pubic  symphysis,  or 
in  the  direction  taken  by  the  displaced  urethra.  On  this  account 
a  male  instrument,  or  the  French  elastic  catheter  are  to  be  pre- 
ferred. In  prolapse  of  the  uterus,  a  pouch  which  is  below  the 
level  of  the  urethra  is  frequently  formed  by  the  dragged  down 
portion  of  the  bladder  connected  with  the  neck  of  the  organ. 
In  this  pouch  the  urine  accumulates,  and  ma}^  give  rise  to  cys- 
titis, unless  it  be  evacuated. 

VII.  Inordinate  distention  of  the  rectum  may  be  mentioned 
as  another  cause  of  retention  of  urine.  The  obstruction  may 
[iroceed  from  excessive  accumulation  of  feces,  or  from  the  im- 
paction of  a  large  quantity  of  undigested  food  or  foreign  bodies. 
Some  years  ago,  a  man,  aged  sixty,  was  brought  to  King's  College 
Hospital,  London,'  with  retention  of  urine,  caused  by  the  lodg- 
ment in  the  rectum  of  upwards  of  a  pint  of  common  gray  peas, 
which  had  been  swallowed,  in  a  dry  state  and  almost  without 
mastication,  six  days  previously.  They  had  undergone  no  change 
in  the  stomach,  but,  in  their  transit  through  the  bowel,  thc}^  had 
become  swollen  by  the  absorption  of  moisture,  and  the  greater 
number  had  accumulated  in  the  rectum,  where  the}^  formed  a 
solid  mass  which  occupied  almost  the  entire  pelvic  cavity,  and 
which,  hy  compressing  the  urethra  and  the  neck  of  the  bladder, 
had  etlectually  prevented  the  discharge  of  the  urine.  It  Avas 
with  no  little  difficulty  that  a  catheter  could  be  introduced  after 

'  Dr.  Geo.  Johnson,  London  Medical  Gazette,  vol.  x.xx.  p.  OO.j. 


120  RETEXTIOX    OF    URIXE. 

deatli.  Dr.  W.  11.  Westcott,  of  Massachusetts,  recently  reported 
a  case  of  retention  of  urine,  in  a  boy  eight  years  old,  caused  by 
lodgment  in  the  rectum  of  upwards  of  six  ounces  of  cherry- 
stones. The  excessive  distension  of  the  bowel  prevented  the 
passage  of  the  catheter. 

The  proper  remedy  for  this  form  of  retention  is  clearance  of 
the  rectum  by  means  of  the  scoop,  spoon,  or  forceps,  according 
to  the  nature  of  the  obstructing  substance,  aided,  if  necessary,  by 
stimulating  or  oleaginous  injections.  The  catheter  is  used  if  it 
is  required, 

YIII.  There  is  a  variety  of  retention  of  urine  which  is  occa- 
sionally met  with  in  hysterical  females,  and  which  seems  to  be 
dependent  rather  upon  a  deficiency  of  volition  than  upon  paralysis 
of  the  muscular  libres  of  the  bladder.  The  patient  cannot,  or 
thinks  she  cannot,  urinate,  and,  therefore,  does  not  try  to  relieve 
herself.  The  affection  is,  in  general,  only  temporary,  but  may 
last  for  several  days,  weeks,  or  even  years.  Purgatives,  assa- 
foetida  clysters,  and  the  internal  use  of  chloral  and  bromide  of 
potassium,  and  iron,  are  the  remedies  mainly  to  be  relied  upon. 
Cold  water,  poured  upon  the  sacrolumbar  region  in  a  continuous 
stream,  from  a  heiglit  of  three  or  four  feet,  often  afibrds  speedy 
relief.  The  catheter  must,  if  possible,  be  avoided,  and  in  all  in- 
stances, especially  when  there  is  reason  to  believe  that  the  com- 
plaint is  feigned,  it  is  of  great  importance  not  to  encourage  the 
patient  by  an  appearance  of  commiseration.  In  a  case,  under 
my  charge  some  years  ago,  the  affection  had  persisted  for  upwards 
of  four  months,  during  which  period  the  urine  was  drawn  off 
twice  every  twenty-four  hours.  The  application  of  a  large 
blister  to  the  sacrolumbar  region,  and  threats  to  employ  the 
actual  cautery,  were  finally  followed  by  comjjlete  recoveiy. 

A  form  of  retention,  dependent  upon  deficient  volition,  is 
sometimes  met  with  in  the  male.  In  the  case  of  one  of  m}^ 
patients,  of  rather  delicate  constitution,  and  a  nervous,  melan- 
cholic temperament,  the  attacks  were  produced  by  close  study, 
mental  anxiety,  and  physical  exhaustion,  and  were  liable  to  be 
greatly  influenced  by  mental  emotion.  Whenever  he  travels, 
his  mind  always  becomes  deeply  absorbed  by  his  ailments ;  he 
fancies  that  he  will  be  unable  to  pass  his  urine,  and  the  conse- 
quence is  that,  when  he  makes  the  effort,  he  utterly  fails,  no 
matter  how  powerfully  he  may  exert  himself.     As  soon,  how- 


CATHETERISM.  121 

ever,  as  he  goes  to  some  retired  place,  he  can  relieve  himself 
with  the  greatest  facility.  He  has  tried  this  experiment 
repeatedly,  and  always  with  the  same  result. 

It  is  to  this  form  of  retention  of  urine  that  Sir  James  Paget 
has  applied  the  term  "stammering  of  the  bladder,"  to  wdiich 
allusion  has  already  been  made  at  page  57.  In  consequence  of 
a  disturbance  of  coordination  between  the  sympathetic  and 
motor  nerves  distributed  to  the  bladder,  there  is  a  want  of 
consentaneous  action  between  the  detrusor  and  sphincter  muscles, 
and  a  species  of  temporary  paralysis  results.  In  a  case  of  this 
description,  occurring  in  a  girl,  eighteen  years  of  age,  Professor 
Richardson,^  of  N^ew  Orleans,  afforded  prompt  relief  by  dividing 
the  upper  wall  of  the  urethra  in  its  entire  extent,  wdiereby  its 
muscular  fibres  w^ere  placed  in  a  state  of  rest. 

IX.  Finally,  there  is  a  form  of  retention  of  urine,  which  may 
be  said  to  be  periodical  in  its  character,  as  it  comes  on  at  a  par- 
ticular time,  very  much  like  an  attack  of  intermittent  fever, 
being  evidently  dependent  upon  similar  causes.  The  retention 
occurs  at  a  certain  period  of  the  day,  and,  after  having  continued 
for  some  hours,  it  either  disappears  spontaneously,  the  bladder 
gradually  regaining  its  expulsive  power,  or,  as  perhaps  more 
connnonly  happens,  relief  is  obliged  to  be  afforded  with  the 
catheter.  The  organ  then  recovers  its  natural  tone,  and  retains 
it  until  the  time  arrives  for  another  attack,  which  usually 
happens  about  the  same  period  every  other  day,  thus  bearing 
the  closest  resemblance  to  a  tertian  ague.  There  can  be  no 
doubt  that  the  immediate  cause  of  this  affection  is  malaria,  the 
effects  of  which  explode  upon  the  muscular  fibres  of  the  bladder, 
temporarily  irritating  and  paralyzing  them,  and  thus  disqualify- 
ing theju  for  the  discharge  of  their  proper  functions.  The 
treatment  must,  of  course,  be  by  quinine,  either  alone  or  in 
union  with  arsenic  and  other  antiperiodic  remedies;  the  bowels 
and  secretions  must  receive  due  attention;  and  the  distended 
bladder  must  be  promptly  evacuated  wath  the  catheter. 

Sect.  II.— CATHETERISM. 

The  introduction  of  the  metallic  catheter,  although  apparently 
very  simple,  is  one  of  the  nicest  and  most  delicate  processes  in 

'  New  Orleans  Journal  of  Medicine,  Oct.  1869,  p.  G86. 


122  RETENTION    OF    URINE. 

surgery.  It  requires  skill  of  the  highest  order,  as  well  as  the 
most  intimate  knowledge  of  the  anatomy  of  the  urinary  organs. 
If  I  were  called  upon  to  state  what  I  considered  as  the  most 
important  operation  that  a  practitioner  is  obliged  to  perform,  I 
should  unhesitatingly  say  the  introduction  of  the  catheter.  It 
is  true,  the  most  untutored  and  awkward  surgeon  may  occasion- 
all}' ,  nay,  perhaps  not  unfrequently,  reach  the  bladder  without 
difficult}^ ;  but  let  such  an  individual  attempt  the  passage  of  the 
instrument  when  there  is  some  meclianical  obstacle,  as  a  stricture 
or  an  enlarged  prostate,  or  spasmodic  contraction  of  the  muscular 
fibres  of  the  urethra,  and  he  will  be  sure  to  be  foiled.  The 
moment  the  catheter  is  arrested  he  becomes  bewildered ;  his 
hand  trembles,  dismay  is  depicted  in  every  feature,  large  drops 
of  sweat  stand  upon  his  brow,  and  his  whole  frame  is  paral^'zed. 
If,  under  these  circumstances,  he  proceed,  he  will  almost  inevi- 
tably produce  a  false  passage,  and  occasion  the  consulting 
surgeon  some  difficulty  in  overcoming  it ;  if,  indeed,  he  does  not 
actually  endanger  the  life  of  his  patient.  To  avoid  such  an 
occurrence,  as  disgraceful  as  it  is  unfortunate,  the  introduction 
of  metallic  instruments  should  alone  be  entrusted  to  skilled 
practitioners. 

Catheters  are  cylindrical  tubes,  varying  in  their  composition, 
size,  and  shape.  The  best  are  made  of  silver,  and  are,  for  an 
adult,  about  nine  inches  and  a  half  long,  by  six  or  seven  milli- 
metres in  diameter;  they  are  perfectly  smooth,  light,  and  bent 
at  the  vesical  extremity  to  accommodate  them  to  the  natural 
curve  of  the  fixed  urethra,  which,  as  originally  pointed  out  by 
Mr.  Briggs,  of  London,  corresponds  to  rather  less  than  one-third 
of  the  circumference  of  a  circle  three  inches  and  a  quarter  in 
diameter,  or  an  arc  of  such  a  circle  subtended  by  a  chord  two 
inches  and  three-quarters  long.  An  instrument,  usually  known 
as  that  of  Sir  Henry  Thompson,  the  axis  of  the  point  of  which 
forms  a  right  angle  with  the  axis  of  the  shaft,  fashioned  to  this 
curve,  will  generally  pass  through  the  average  urethra  without 
the  slightest  difficulty.  A  catheter,  constructed  on  these  princi- 
ples, is  represented  on  a  scale  of  one-half  its  actual  size  in  fig.  21. 
In  children  and  adults  below  the  average  stature,  the  curve  should 
describe  an  arc  of  a  smaller  circle;  while  jn  corpulent  persons 
it  should  form  a  segment  of  a  larger  circle.  The  vesical  extrem- 
ity, or  beak,  which  is  rounded  off,  but  closed,  is  provided  with  a 


CATHETEEISM, 


123 


smoothly  bevelled  ovoidal  opening  on  each  Fig.  21. 

side,  three  lines  long  and  a  line  in  width, 
for  the  entrance  of  the  urine.  The  other 
extremity,  usually  called  the  handle,  is  open, 
and  is  furnished  with  two  rings,  which  serve 
the  double  purpose  of  enabling  the  surgeon 
to  judge  of  the  exact  position  of  the  beak 
when  it  is  buried  out  of  sight,  and  of  secur- 
ing it  in  its  place  when  it  is  necessary  to 
retain  it  in  the  bladder.  The  flexible  English 
catheter,  if  used  with  a  stylet,  possesses  no 
advantages  over  the  silver  instrument;  but 
it  will  retain  an}'  curve  that  the  surgeon 
ma}'  desire  to  give  it,  by  moulding  in  hot 
and  immediately  transferring  it  to  cold  water. 
The  French  elastic  instruments,  shown  in 
figs.  17  and  18,  are  perfectly  soft  and  flexible, 
and  are  so  easy  of  introduction,  and  so  utterly 
incapable  of  doing  harm,  that  they  may  be 
entrusted  to  the  patient  or  his  nurse.  These 
contrivances  cannot  be  too  warmly  recom- 
mended to  inexperienced  practitioners;  but 
their  cost  and  lial)ility  to  crack,  it  is  feared, 
will  prevent  their  general  adoption  in  this 
countr}'.  Every  surgeon  should  have  an 
assortment  of  catheters,  of  ditrerent  com- 
position and  dimensions,  in  order  that  he 
may  be  prepared  for  any  emergency.  The 
straight  metallic  catheter,  although  easily 
introduced,  is  not  much  in  vogue. 

When  the  urethra  is  entirely  sound,  a  toler- 
ably large  catheter,  one  that  will  gently  dis- 
tend the  parietes  of  the  tube,  is  selected.  An 
instrument  of  this  size  will,  in  general,  glide 
along  much  more  easily  than  a  smaller  one,  since  it  is  not  so 
liable  to  be  arrested  by  the  folds  and  follicles  of  the  mucous 
membrane,  or  to  impinge  against  the  margins  of  the  opening  in 
the  triangular  ligament.  Before  introducing  it,  it  should  always 
be  well  oiled,  and  carefully  warmed  Ijy  rubbing  it  between  the 
thumb  and  fingers,  or  by  plunging  it  into  hot  water. 


Silver  Catlieler. 


124  RETEXTIOX    OF    URINE. 

Tlio  catheter  may  be  introduced  while  the  patient  is  standing, 
sitting,  or  Ij'ing ;  but,  whatever  posture  may  l^e  selected,  it  is 
important  that  the  thighs  should  be  moderately  separated  from 
eaclj  other,  and  flexed  upon  the  pelvis,  to  relax  the  abdominal 
muscles.  In  the  first  ease,  the  patient  leans  with  his  nates 
against  the  wall,  advances  and  separates  his  feet  a  few  inches, 
and  inclines  his  chest  slightly  forwards,  so  that  he  may  not 
change  his  position  during  the  operation.  The  -surgeon  may 
take  his  place  either  at  the  front  or  side.  If  he  sit,  the  breech 
should  project  over  the  chair,  and  the  body  be  directed  backwards. 
The  position  of  the  operator  is  the  same  as  before.  The  most 
convenient  posture,  however,  is  the  recumbent.  The  patient  lies 
on  his  back,  near  the  edge  of  the  bed,  the  head  being  supported 
by  a  pillow,  and  the  knees,  slightly  separated  from  each  other, 
somewhat  raised.  The  surgeon,  standing  by  the  left  side  of  the 
bed,  takes  the  penis  in  the  left  hand,  and  lifts  it  to  a  right  angle 
with  the  bod}',  to  efface  the  curve  which  it  forms  at  the  pubes. 
The  catheter,  held  in  the  riglit  hand,  between  the  thumb  and 
first  two  fingers,  is  inserted  into  the  orifice  of  the  urethra,  its 
concavity  being  directed  towards  the  pubes,  and  the  handle 
being  nearly  in  contact  with  the  median  line  of  the  abdomen. 
The  instrument  is  now  passed  onward,  until  its  beak  reaches  the 
sinus  of  the  bulb,  which  lies  upon  the  anterior  surface  of  the  tri- 
angular ligament,  rather  deep  in  the  perineum.  To  disengage  it 
from  this  depression,  the  handle  is  changed  from  the  horizontal 
direction,  in  which  it  has  hitherto  been  held,  into  the  vertical, 
at  the  same  time  that  the  point  is  slightly  retracted.  By  this 
manoeuvre,  the  curved  portion  is  brought  under  the  arch  of  the 
pubes,  and  immediately  opposite  the  opening  in  the  triangular 
ligament.  By  depressing  now  the  handle  of  the  instrument  on 
a  level  with  the  thighs,  or,  rather,  a  little  between  them,  its 
beak  glides  readily  over  the  prostatic  part  of  the  urethra  into 
the  bladder. 

In  performing  this  operation,  no  force  is  employed;  on  the 
contrary,  the  whole  proceeding  is  conducted  with  the  utmost 
gentleness.  The  catheter,  held  as  lightl}-  as  possible,  is  made  to 
glide  along,  as  it  were,  by  its  own  Aveight  and  by  that  of  the 
hand.  The  penis  sliould  be  drawn  slightly  forward  over  the 
instrument,  just  sufficiently  to  render  the  urethra  a  little  tense. 
Everything  like  stretching  and  pulling  must  be  avoided. 


CATHETERISM.  125 

In  introducing  the  straight  catheter,  the  patient  lies  on  his 
back,  and  the  surgeon  stands  on  the  right  side  of  the  bed,  instead 
of  on  the  left,  as  in  the  other  case.  The  penis  is  held  in  the  left 
hand,  at  a  right  angle  with  the  body,  and  the  instrument  is 
carried  down  perpendicularly  as  far  as  the  sinus  of  the  bulb.  To 
free  it  from  this  depression,  the  point  is  retracted  two  or  three 
lines,  and  then,  while  the  penis  is  lowered  between  the  thighs, 
it  is  at  once  pushed  onward  into  the  bladder. 

The  natural  obstacles  to  the  passage  of  the  catheter  are  the 
lacuna  magna,  the  sinus  of  the  bulb,  and  the  margins  of  the 
opening  in  the  triangular  ligament.  The  first  is  easily  avoided 
by  using  a  large  instrument  with  a  rounded  instead  of  a  conical 
point;  the  second,  b}"  withdrawing  it  two  or  three  lines  before 
it  is  pushed  on ;  and  the  last,  by  carrying  it  parallel  with  the 
raphe  of  the  perineum,  and  not  more  than  an  inch  below  the 
arch  of  the  pubes.  The  orifices  of  the  prostatic  and  seminal 
ducts,  the  sinus  pocularis,  and  the  gallinaginous  crest,  can  hardly 
be  considered  as  ofliering  any  opposition  to  the  progress  of  the 
instrument.  When  the  prostate  gland  is  enlarged,  the  finger, 
introduced  into  the  rectum,  will  enable  the  surgeon  to  push  the 
catheter  forward  toward  the  pubes,  or  toward  either  side,  as  cir- 
cumstances ma}'  require. 

Difficulty  is  occasionally  experienced  in  entering  an  instrument 
at  the  external  meatus.  I  have  repeatedly  encountered  this 
impediment,  both  in  ordinary  catheterism,  in  sounding,  and  in 
lithotom}-.  In  general,  it  is  produced  by  an  unusually  narrow 
orifice,  attended  with  very  hard,  tight  edges,  evincing  but  little 
disposition  to  dilate ;  sometimes  it  is  caused  by  a  hypospadic 
condition  of  the  part ;  and  in  some  instances,  again,  it  is  depen- 
dent upon  a  very  narrow  opening  in  the  prepuce,  the  result  either 
of  disease  or  of  a  congenital  vice.  The  impediment  may  also 
arise  from  a  very  long  and  bulky  foreskin,  especially  if  there  be 
at  the  same  time  an  uncommonly  small  orifice.  In  such  a  case, 
as  I  have  had  occasion  to  witness  more  than  once,  the  point  of  the 
instrument,  instead  of  entering  the  meatus,  will  be  very  apt  to 
pass  between  the  head  of  the  penis  and  its  preputial  investment. 

The  proper  remedy  in  most  of  these  cases  is  incision ;  a  narrow 
bistoury  being  introduced,  the  faulty  orifice  is  enlarged  to  the 
requisite  extent,  after  which  it  is  permitted  to  heal  over  a  tent, 
confined  by  a  narrow  adhesive  strip,  and  retained  until  the  object 


126 


RETENTIOX    OF    URIXE. 


Fis. 


is  attained.  If  the  obstacle  is  occasioned  by  a  long  and  narrow 
prepuce,  relief  is  attempted  b}"  means  of  a  narrow,  slender  bivalve 
speculum,  with  which  the  parts  are  gently  but  elfectually  dilated : 
or,  this  failing,  the  redundant  structures  are  split  open,  or  cleft 
and  ablated,  as  in  the  operation  of  circumcision. 

Various  contrivances  are  used  for  retaining  the  catheter  in  the 
bladder.  The  one  which  I  usually  prefer  consists  of  a  double  T- 
bandage,  the  two  thigh-pieces  of  which  are 
fastened,  so  as  not  to  interfere  with  the  anus 
and  the  scrotum.  The  instrument,  having 
been  introduced,  is  secured  by  two  strips  of 
linen,  or  tape,  by  tying  the  miHdle  of  each  to 
the  ring  of  the  catheter,  and  the  ends  to  the 
vertical  bands.  Another  very  good  plan  is 
to  surround  the  penis  with  an  ivory,  elastic, 
or  linen  3'oke,  and  to  secure  this  against  the 
pubes  by  means  of  four  pieces  of  tape,  carried 
round  the  thiglis  and  pelvis.  The  catheter 
is  then  fastened  to  the  ring  or  yoke  in  the 
usual  manner. 

For  retaining  the  soft  gum  catheter,  by  far 
the  best  device  is  that  represented  in  fig.  22. 
It  is  of  French  manufacture,  and  is  composed 
of  bands  of  gum  elastic,  whereby  it  is 
rendered  incapable  of  injuring  the  penis,  in 
the  event  of  an  erection.  The  opening  at  the 
point  of  crossing  of  the  bands  holds  the  in- 
strument very  securely. 

It  is  not  to  be  forgotten  that  a  catheter,  if 
allowed  to  remain  too  long  in  the  bladder,  or 
if  improperly  lodged  in  this  organ,  may  cause 
very  serious,  if  not  fatal  injury.     When  the 
instrument  is  introduced  too  far,  or  retained 
too  forcibly,  its  extremity  must  necessarily 
exert  undue  pressure  upon  the  mucous  mem- 
brane, and  through  it  upon  the  other  tunics, 
followed,  if  it  be  not  speedily  moderated,  by 
sloughing  and  perforation,  and  eventually  by  tlie  escape  of  the 
urine  into  the  peritoneal  cavity,  or  into  the  surrounding  connec- 
tive tissue.  In  the  former  case,  the  accident  is  always  necessarily 


Mode  of  securing  tlie 
(5um  Catlieler  ia  the 
Bladder. 


CATHETERISM, 


127 


Fis?.  23. 


Holfs  Catheter 


fata],  and  in  the  latter  it  is  very  apt  to  become  so,  either  soon 

after  its  occurrence,  or  at  an  indefinite  period.     One  great  fault 

which    most   practitioners  commit  when   they 

have  occasion  to  retain  a  catheter  in  the  bladder, 

is  that  they  employ  too  long  a  one,  and  a  second, 

and  not  less  serious  one,  that  they  retain  it  too 

long  in  one  position.     To  answer  the  purpose, 

the  instrument  should  be  at  least  from  an  inch 

to  an  inch  and  a  half  shorter  than  one  used  for 

merely  drawing  off   the   urine,  and   its    beak 

should  rest  just  within  the  vesical  orifice  of  the 

urethra.     What  is  called  Symes'  catheter  is  by 

far  the  most  suitable  of  the  metallic  instruments 

for  permanent  retention ;  while  the  blunt  French 

elastic  instrument  is  the  best  of  the  soft  ones. 

The  winged  or  self-retaining  catheter  of  Mr. 

Holt,  represented   in   fig.    23,  can  never    come 

into  general  use,  on  account  of  the  irritation  it 

is  liable  to  set  up,  and  its  frequent  failure  to  ajisw^er  the  purpose 

for  which  it  is  intended. 

The  urethra  seems  to  possess  some  peculiar  morbid  sjmipa- 
thies,  through  which  the  introduction  of  the  catheter  is  some- 
times followed  by  unpleasant  efiects,  as  partial  syncope,  shock, 
epileptiform  convulsions,  and  even  death.  These  occurrences  are 
most  common  in  persons  of  a  nervous,  irritable  temperament, 
or  who  have  sufifered  from  intermittent  fever,  or  lived  in  hot 
climates ;  and  cannot  always  be  prevented,  however  cautiously- 
the  operation  may  be  performed.  The  best  way  to  avoid  them 
is  to  insert  the  instrument  in  the  recumbent  poosture,  as  they 
almost  invariably  happen  when  it  has  been  passed  when  the 
patient  was  standing.  In  the  event  of  the  efiects  not  passing 
off*  speedily,  the  most  suitable  remedies  are  hot  alcoholic  drinks, 
the  inhalation  of  chloroform,  and  the  hypodermic  use  of  morphia. 

Catheterism  in  the  female  is  easy  enough,  unless  the  urethra 
happens  to  be  displaced  by  the  weight  of  the  uterus  or  tlie 
pressure  of  some  morbid  growth,  in  which  event  it  is  occasion- 
ally attended  with  great  difiiculty.  It  should  always  be  per- 
formed under  cover  of  the  clothes,  while  the  patient  lies  upon 
her  back  near  the  edge  of  the  bed.  Ocular  inspection  can  be 
justifiable  only  when  the  parts  are  in  a  state  of  great  disease,  or 


128  RETENTION    OF    UEINE. 

when  the  canal  has  undergone  much  change  in  its  relative  posi- 
tion. The  best  mode  of  proceeding  is  to  apply  the  index  finger 
of  the  left  hand  to  the  upper  margin  of  the  orifice  of  the  vagina, 
which  thus  serves  as  a  guide  to  the  instrument,  which  is  placed 
upon  its  palmar  surface,  represented  in  fig.  24,  and  then  moved 

Fi2r.  24. 


Mode  of  holding  the  Female  Catheter. 

upwards  along  the  middle  line,  until  its  point  arrives  at  the 
dimple-shaped  depression  marking  the  situation  of  the  mouth  of 
the  urethra.  The  catheter  is  then  jiassed  on  with  its  concavity 
upwards  until  it  reaches  the  interior  of  the  bladder ;  a  circum- 
stance which  will  be  indicated  by  the  want  of  resistance  and  the 
flow  of  the  urine.  Or,  instead  of  this,  the  finger  may  be  placed 
upon  the  clitoris,  just  below  the  commissure  of  the  nymph^e, 
and  the  instrument  carried  from  thence  downwards  along  the 
central  line  of  the  vestibule,  until  its  point  slips  into  the  tube. 
When  there  is  much  difiiculty  in  performing  the  operation,  in 
consequence  of  a  change  in  the  direction  of  the  urethra,  the 
ordinary  instrument  may  be  conveniently  replaced  by  a  gum-  J 
elastic  one.  • 

The  female  catheter  is  made  of  silver,  and  is  not  more  than 
five  inches  in  length.  Its  vesical  extremity  is  somewhat  bent,  | 
to  adapt  it  to  the  shape  of  the  urethra,  and  is  perforated  with 
numerous  foramina,  instead  of  having  eyelets,  as  in  the  male 
instrument.  The  other  end  is  provided  with  two  rings,  in 
order  to  fasten  the  instrument,  when  it  is  necessary  to  retain  it 
in  the  bladder,  by  means  of  tapes,  to  a  T-bandage.  When  the 
urethra  has  been  materially  changed  in  its  direction,  the  most 
suitable  instrument  will  be  a  gum  catheter,  or  the  ordinary 
silver  male  catheter. 

Tlie  employment  of  the  female  catheter  is  liable  to  be  attended 
with  some  curious  accidents.     Thus,  as  has  long  been  known,  if 


PUXCTURE    AXD    ASPIRATIOX    OF    THE    BLADDER.       129 

it  is  not  provided  witli  rings,  it  may  slip  into  the  bladder,  being 
suddenly  and  unexpectedly  drawn  from  tlie  fingers  of  tbe  sur- 
geon. A  similar  accident  may  happen  to  the  male,  as  is  exem- 
plified by  bits  of  bougie,  straw,  leather,  pencil  cases,  and  other 
foreign  bodies.  If  the  entire  catheter  never  slips  into  the  blad- 
ber  of  the  male,  it  is  only  because  of  the  greater  length  and 
curvature  of  the  urethra  and  the  instrument.  This  occurrence 
is  due  to  the  constant  vermicular  contraction  of  the  walls  of  the 
canal,  which  passes  towards  the  bladder,  and  to  the  suction- 
force  exerted  by  the  latter  organ. 

In  the  second  place,  great  diflScidty  may  attend  the  with- 
drawal of  the  female  catheter.  In  a  case  of  this  nature,  which 
fell  under  my  observation,  the  ordinary  instrument,  provided 
with  lateral  eyelets,  caused  neither  pain  nor  inconvenience  as 
long  as  it  was  kept  at  rest ;  but  the  moment  an  attempt  was 
made  to  withdraw  it,  it  was  found  to  be  so  firmly  grasped,  that 
it  could  only  be  removed  under  chloroform,  when  it  was  forci- 
Idy  extracted,  with  the  eftect  of  slightly  lacerating  the  mucous 
membrane.  The  occurrence  is  doubtless  due  to  spasm  of  the 
muscular  structure  of  the  neck  of  the  bladder  and  urethra,  and 
the  intrusion  of  a  fold  of  mucous  membrane  in  the  lateral  eyelets 
of  the  instrument.  To  avoid  this  contingency,  as  awkward  as 
it  is  painful,  numerous  small  apertures  should  replace  the  open- 
ings of  the  catheter. 

Sect.  III.— PUNCTURE  AND  ASPIRATION  OF  THE  BLADDER. 

I.  When  the  catheter  and  other  means  have  failed  to  produce 
relief,  the  only  thing  that  remains  is  to  tap  the  distended  blad- 
der. Fortunately,  this  operation  is  seldom  necessary  ;  and  thus 
far  I  have  been  obliged  to  perform  it  only  twice,  and  then  in 
cases  not  my  own.  It  is  only  in  instances  of  excessive  hypertro- 
phy of  the  prostate,  attended  with  great  swelling  and  tenderness  of 
the  surrounding  parts,  in  laceration  of  the  urethra,  infiltration 
of  urine  into  the  scrotum,  and  in  deep-seated  impassable  stricture, 
that  the  procedure  should  ever  be  thought  of. 

There  are  four  routes  by  which  the  bladder  may  be  approached 

when  this  operation  becomes  necessary,  namely,  the  rectum,  the 

hypogastric  region,  the  pubic  symphysis,  and  the  sul)pubic  arch. 

<  >t'  these,  the  first  is  the  one  usually  preferred,  on  account  of  the 

9 


130 


RETENTION    OF    URINE. 


facility  of  perfonuiiiij  the  operation,  and  its  supposed  freedom  from 
the  danger  of  urinary  infiltration.  It  is,  of  course,  contraindicated 
when  there  is  great  enlargement  of  the  prostate  gland,  or  serious 
disease  of  the  anus,  rectum,  or  has-fond  of  the  hladder.  Under 
such  circumstances,  the  suprapubic  region  is  selected. 

a.  The  puncture  by  the  rectum  is  executed  with  a  curved 
trocar,  seven  or  eight  inches  in  length,  and  provided  with  a 
(•anula.  The  rectum  being  cleared  out  by  an  enema,  the  breech 
of  the  patient  is  brought  over  the  edge  of  the  hed,  and  liis  legs 
are  supported  by  two  assistants,  as  in  the  operation  for  stone, 
while  a  third  assistant  presses  the  bladder  downwards.  The 
surgeon,  oiling  the  index  and  middle  fingers  of  the  left  hand, 
introduces  them  into  the  bowel,  in  contact  with  its  anterior 
wall ;  he  now  takes  the  instrument  in  the  right  hand,  retracts 
the  point  of  the  trocar  within  its  sheath,  and  then  places  it  in 
the  groove  formed  by  the  junction  of  the  two  fingers  in  the  anus. 
The  only  thing  that  remains  to  be  done  is  to  carry  the  instru- 
ment on  until  it  bas  fully  passed  the  posterior  margin  of  the 
[trostatc,  when,  b}'  depressing  its  handle,  the  point  is  urged  on 
through  the  superim[)Osed  structures  into  the  interior  of  the 
Itladder,  as  is  shown  in  fig.  25.     The  want  of  resistance  and  a 

Fiff.  25. 


Rectal  I'uuctin-e  of  the  Blajile 


slight  escape  of  urine  will  indicate  tbat  the  instrument  has 
reached  its  destination.  By  a  sort  of  double  movement,  the 
trocar  is  now  withdrawn  and  the  canula  pushed  farther  on  int< 
the  distended  viscus.  Tlie  urine  being  evacuated,  the  canula  is 
either  at  once  removed,  or,  if  there  be  anv  serious  obstacle  aloni 


PUNCTURE    AXD    ASPIRATION    OF    THE    BLADDER.      131 

the  natural  passage,  it  is  retained  until  this  is  surmounted.  In 
tlie  latter  case,  the  instrument  is  secured  bj  a  T-bandage. 

The  operation  by  tlie  rectum  is  simple  enough  ;  it  requires 
little  skill,  and  is  performed  in  a  few  seconds.  It  is,  however, 
not  devoid  of  dangers  and  drawbacks.  During  its  performance 
the  bladder  has  been  transfixed  or  missed  altogether ;  the  deferent 
ducts  and  seminal  vesicles  have  been  wounded,  and,  in  one 
instance  at  least,  the  inflammation  has  extended  to  the  testicle, 
which  suppurated ;  aljscesses  have  formed  between  the  Ijladder 
and  rectum  in  the  track  of  the  canula ;  the  peritoneum  may 
descend  very  low  and  be  wounded  ;  a  jiermanent  fistula  may 
remain  between  the  bladder  and  the  bowel,  iiermitting  a  recipro- 
cal interchange  of  their  contents  ;  infiltration  of  urine  is  to  be 
<lreaded  ;  and  several  cases  have  been  reported  in  which  it  gave 
rise  to  emphysema,  the  rectal  flatus  diffusing  itself,  not  only 
through  the  connective  tissue  of  the  pelvis  and  down  the  thighs 
and  nates,  but  even  to  the  upper  parts  of  the  body,  and  eventu- 
ating in  the  death  of  the  patient.  On  these  accounts,  and  par- 
ticularly if  the  retention  be  due  to  impassable  stricture,  I  think 
that  the  operation  is  far  inferior  to  laying  open  the  membranous 
urethra  through  the  perineal  raph^. 

/3.  Puncture  of  the  bladder  above  the  pubes  has  generally  been 
regarded  as  even  more  objectionable  than  by  any  other  route, 
not  l)ecause  of  any  particular  difficulty  in  the  operation,  but 
because  of  its  greater  liability,  as  has  been  conjectured,  to  be 
followed  by  an  escape  of  urine  into  the  peritoneal  cavity  and 
the  surrounding  connective  tissue.  Both  events  are  to  be  dreaded, 
especially  the  former,  which  is  almost  certainly  fatal  in  from 
thirty-six  to  forty-eight  hours  from  its  occurrence.  It  is,  how- 
ever, indicated  when  the  hypertrophy  of  the  prostate  is  so  great 
as  to  render  access  to  the  bladder  through  the  rectum  imprac- 
ticable, and  in  cases  in  which  an  artificial  outlet  for  the  urine  is 
desirable  for  a  long  period.  In  executing  it,  the  patient  is  placed 
on  his  back,  the  skin  is  divested  of  hair,  and  an  incision  is  made 
along  the  median  line,  from  an  inch  to  an  inch  and  a  half  in 
length,  according  to  the  leanness  or  obesity  of  the  part,  down  to 
and  through  the  linea  alba.  Through  this  opening  the  bladder, 
previously  steadied  by  the  hands  of  an  assistant,  is  punctured  at 
its  lowest  part,  by  means  of  a  trocar,  such  as  is  used  in  tapping 
the  abdomen,  the  point  of  the  instrument  being  inclined  ob- 


132 


retextion  of   urixe. 


liquely  dowmvards  and  backwards  in  tlie  direction  of  the  prom- 
ontory of  the  sacrum.  Transfixion  being  completed,  the  trocar 
is  Avithdrawn,  and  the  cannla  gently  passed  into  the  bladder, 
where  it  is  retained  by  an  appro[)riate  bandage,  until  the  ob- 
structing cause  necessitating  the  operation  has  been  removed. 
Instead  of  the  canula,  an  elastic  catheter,  or  a  double  silver  tube, 
n:iade  on  the  principle  of  a  tracheotomy  tube,  and  represented  in 
fig.  26,  may  be  used.     The  patient  in  the  mean  time  lies  on  his 

Fisr.  26. 


Tube  to  be  trora  after  Suprapubic  Puncture  of  the  Bladder. 

side,  to  promote  the  escape  of  the  urine.     Mr.  Abernethy,  who 
gave  a  decided  preference  to  this  mode  of  puncturing  the  blad- 
der, often  performed  the  operation  with  no  other  apparatus  than 
a  pocket  scalpel  and  a  lancet ;  he  did  not  even  always,  it  seems, 
leave  a  canula  in  the  organ,  the  collapse  of  this  sac  sometimes 
preventing  him  from  finding  the  opening  he  had  made  into  it. 
Notwithstanding  this,  he  never  witnessed  any  ill  eflects  from 
the  procedure,  such  as  eftusion  of  urine  into  the  connective  tissue, 
or  the  peritoneal  cavity.     ISo  hemorrhage  attends  the  operation.| 
I  recollect  a  singular  instance  of  hypogastric  paracentesis  of 
the  bladder,  in  which  the  puncture,  after  having  been  perfectly 
healed,  reopened  after  a  lapse  of  fourteen  years.     The  patient,] 
a  farmer  by  occupation,  was  upwards  of  seventy-two  years  oi 
age  at  the  time  of  his  death.     In  the  autumn  of  1831,  while  on! 
a  visit  to  the  interior  of  Indiana,  he  was  seized  with  retention] 
of  urine,  for  which  a  physician  performed  the  operation  in  ques-j 
tion,  although  it  was  doubtless  unnecessary.     For  several  monthsl 
he  wore  a  tube  in  the  wound  ;  upon  laying  aside  which  the  jjartj 
speedily  cicatrized,  and  so  continued   until  about  four  weeks! 
before  he  died,  when,  all  at  once,  it  reopened,  the  integuments 
having  been  the  seat,  for  several  days,  of  erysipelatous  inflam- 
mation.    Urine  afterwards  continued  to  discharge  through  the! 
abnormal  passage  up  to  the  time  of  the  patient's  dissolution,  the 
immediate  cause  of  which  was  constitutional  exhaustion. 


PUXCTUEE    AXD    ASPIEATIOX    OF    THE    BLADDER.       133 

y.  ruiicture  of  the  bladder  tliroug-h  the  pubic  s^niiphysis  was 
first  proposed  by  Dr.  Brander,  of  Jersey,  in  1825  ;  and  although 
it  has  been  performed  successfully  in  several  instances, the  number 
of  cases  is  still  too  limited  to  warrant  an  expression  of  opinion 
as  to  its  relative  and  absolute  merits.  A  hydrocele  trocar  of 
medium  size  is  passed  through  the  centre  of  the  symphysis,  some- 
what obliquely  dowuM^ards  and  backwards  towards  the  sacrum, 
and  should  be  entered,  as  the  patient  lies  on  his  back,  at  a  right 
angle  with  the  body.  A  piece  of  liexiljle  catheter  is  then  in- 
serted through  the  canula,  and  retained  in  the  usual  way.  The 
operation,  which  is  perfect!}^  simple,  does  not  involve  any  injury 
to  the  peritoneum,  and  is  entirely  free  from  the  danger  of  infil- 
tration of  urine  ;  no  such  effects,  at  all  events,  have  as  yet  fol- 
lowed it  in  any  instance.  The  passage  of  the  instrument  might 
1)6  impeded  by  ossification  of  the  interpubic  cartilage  ;  but  this 
occurs  chiefly  in  advanced  life,  and  therefore  constitutes  no 
valid  objection  to  the  method. 

6.  Mr.  Voillemier^  has  tapped  the  bladder  bj''  inserting  a  trocar 
by  the  side  of  the  suspensory  ligament  of  the  penis,  that  organ 
having  previously  been  draAvn  downwards  and  backwards,  and 
tilting  the  instrument  backwards  close  behind  the  arch  of  the 
pubes.  In  this  procedure,  which  may  be  termed  the  infrapubic 
puncture,  the  instrument  passes  though  a  space  between  the 
penis  and  the  pubes,  which  becomes  larger  as  it  is  viewed  more 
deeply,  on  account  of  the  divergence  of  the  cavernous  bodies. 
In  the  patient  operated  upon  in  this  way,  the  wound  healed  in 
fortj'-eight  hours. 

II.  A  procedure  for  relieving  the  distended  bladder  which 
will  probably  supersede  the  ordinary  suprapubic  operation  is 
puncture  of  the  viscus  with  capillary  trocars  combined  with 
pneumatic  aspiration,  for  the  introduction  of  which  Ave  are 
mainly  indebted  to  ]\I.  Dieulafoy^  and  other  French  surgeons. 
'J'he  operation  is  certainly  perfectly  harmless,  it  having  been 
repeated  as  many  as  twenty-fivo  times  in  twelve  days ;  and  it 
has  never,  so  far  as  my  knowledge  extends,  been  follo^ved  by 
any  accident. 

The  most  convenient  aspirator,  and  the  one  least  lialde  t6  get 

■  London  Lancet,  Dec.  19,  18G8,  p.  717. 

2  Traitc  de  TAspiration  des  Liquidcs  niorbides,  Paris,  1870. 


13i 


RETENTION    OF    URINE, 


out  of  order,  is  that  of  M.  Potaiii,  represented  in  fig.  27.  The 
essential  parts  of  the  apparatus  consist  of  a  rubber  stopper,  which 
may  T^e  fitted  to  any  sort  of  bottle,  perforated  by  a  branched 
metallic  tube,  provided  with  stopcocks,  to  one  side  of  which  is 


Fig.  2: 


Ai-pirator. 

attaclied  a  gum  tube  communicating  with  an  air-pump  syringe, 
and  to  the  other  a  tube  to  which  the  capillary  trocar  is  fixed. 
The  bottle  having  been  exhausted  of  air  by  the  syringe,  and  the 
proper  attachments  made,  the  delicate  trocar  is  well  oiled  and 
inserted  with  a  rotary  motion  through  tlie  linea  alba,  about  half 
an  inch  above  the  pubic  symphysis,  into  the  bladder.  It  is 
then  withdrawn  sutficiently  to  yjermit  the  shutting  ofi^"  of  the 
stopcock  connected  with  the  canula,  wdien  the  corresponding- 
stopcock  of  the  branched  tube  is  turned  on,  and  the  urine 
rushes  into  the  receiver,  which  should  be  of  suflicient  capacity 
to  obviate  the  necessity  of  repeating  the  procedure.  To  prevent 
the  escape  of  any  of  the  fluid  which  may  remain  in  the  canula 
after  the  operation  is  completed,  the  aspiration  should  be  kept 
up  during  its  withdrawal. 


CHAPTER  VI. 

TUMORS  AND  TUBERCLE  OF  THE  BLADDER. 

Sect.  I.— TUMORS  OF  THE  BLADDER. 

Primary  neoplasms  of  the  bladder  are  uncommon,  the  most 
frequent  lieing  the  fibrous,  carcinomatous,  and  sarcomatous,  while 
the  osseous  and  myomatous  are  exceedingly  rare.  Of  osseous 
growths,  the  only  cases  on  record,  and  the}'  are  probably  nothing- 
more  than  examples  of  tumors  that  had  undergone  calcareous 
transformation,  are  a  bony  cyst,  of  the  volume  of  a  chestnut, 
attached  to  the  posterior  wall  of  the  viscus  of  a  lad,  who  was 
subjected  to  lithotomy  by  Middleton  ;  and  an  ossified  jDeduncu- 
lated  growth,  as  large  as  a  turkey's  egg^  discovered  by  Dupuy- 
tren  in  the  bladder  of  a  woman,  dead  of  cystitis.  A  very 
remarkable  and  unique  case  of  myoma  in  a  boy,  twelve  years  of 
age,  has  recently  been  reported  by  Professor  Billroth.^  The 
tumor,  which  was  upwards  of  eight  inches  in  its  longest,  by  five 
in  its  broadest,  and  three  inches  in  its  basal  circumference,  was 
readily  detected  by  abdominal  and  rectal  palpation,  and  was 
successfully  extirpated  by  the  higli  operation.  Serous,  hydatid, 
and  dermoid  cysts,  developed  originally  in  the  kidneys,  the 
pelvic  cavitj,  the  ovaries,  or  the  Fallopian  tubes,  are  sometimes 
discharged  from  the  urethra,  or  found  after  death  floating  loose 
in  the  bladder,  where  their  presence  was  productive  of  pain  and 
spasm,  with  frequent  micturition,  and  sadden  stoppage  or 
obstruction  of  the  flow  of  urine. 

1.  Fibrous  Tumors. — Vesical  fibroma  presents  itself  under 
several  varieties  of  form,  as  the  tuberous,  papillary,  and  poly- 
poid, of  which  the  last  two  are  the  most  common  and  interesting 
from  a  surgical  point  of  view. 

a.  Tuberous  fibroma,  either  as  a  new  growtli  of  fibrous  tissue, 
or  admixed  with  glandular  elements,  when  it  is  known  as  adenoid 
fibroma,  occurs,  especially  in  young  subjects,  as  a  bosselated, 

'  Lfingunbcck's  Aicliiv,  Bd.  xviii.  p.  411,  1875. 


13G 


TUMOES    AXD    TUBERCLE    OF    THE    BLADDER. 


Fiir.  28. 


circumscribed,  somewhat  elevated,  or  broadly  pedunculated  sub- 
mucous tumor  in  the  vicinity  of  the  trigone  and  neck  of  the 
bladder,  where  it  varies  in  size  from  a  pea  to  a  pigeon's  egg, 
giving  rise  to  symptoms  of  retention  or  difficulty  in  micturition, 
and  very  rarelj'  bleeding,  except  from  instrumental  contact.  It 
sometimes  assumes  a  medullary  appearance  from  proliferation  of 
its  glandular  elements,  the  presence  of  which  points  to  its 
derivation  from  the  prostate,  bearing,  in  this  respect,  a  striking 
analogy  to  outlying  or  detached  growths  in  the  neighborhood  of 
the  thyroid  gland. 

/3.  Papillary  fibroma,  or  villous  growth,  is  by  far  the  most 
frequent  of  the  fibrous  neoplasms ;  but  its  clinical  history  is  so 
little  understood,  even  at  the  present  da}',  that  authors  usually 
confound  it  with  villous  carcinoma,  with  which  it  has  certiiin 
points  of  resemblance,  but  from  which  "it  difters,  not  only  in  its 
gross  and  minute  appearances,  but  in  its  symptoms,  progress,  and 
development,  as  well  as  in  tbe  absence  of  glandular  involvement, 
metastatic  deposits,  and  carcinomatous  cachexia.     With  a  view 

to  attempt  to  clear  up  the  obscurities 
which  surround  it,  twenty  cases  of 
undoubted  benign  villous  tumor  have 
been  collected,  from  the  analysis  of 
which  the  following  account  is 
written. 

I'apillary  fibroma  consists  essen- 
tially of  a  congeries  of  dendritic  or 
variously  branched  villi,  each  of 
which  is  composed  of  a  basement 
niombrane  of  vevy  delicate  fibrous 
tissue,  continuous  with  that  of  the 
mucous  or  submucous  connective 
tissue,  inclosing  one  or  several  en- 
larged and  thin-walled  capillary 
vessels,  arranged  in  loo[)S  with  vari- 
cose dilatations,  as  represented  in 
fig.  28,  from  Bryant,  and  covered 
by  a  more  or  less  dense  layer  of 
colunmar,  or  spheroidal  and  poly- 
hedric  0}iithelial  cells.  The  pathological  product  is  thus  seen 
to  have  its  phj-siological  prototj-pe  in  the  normal  villi  of  tlie 


/"^ 


Beniitu  Vesical  Papilla. 


TUMORS    OF    THE    BLADDER. 


137 


mucous  membraues.  In  some  specimens  the  greater  portion  of 
tlie  bladder  appears  to  be  studded  over  Avith  separate  fine  villi, 
conveying  the  idea  of  papillaiy  hyperplasia  of  its  mucous  coat. 
In  other  cases  the  prolongations  are  thick  and  club-shaiied,  giving 
the  surface  of  the  growth  a  mammillated  look.  In  a  third  class 
of  specimens  tnfts  of  very  delicate  filamentous  Adlli  originate 
from  a  narrow  base,  with  little,  if  any,  solid  element.  In  others, 
again,  the  villous  tumor  shows  itself  as  a  soft  fibrous  growth, 
slightly  elevated  above  the  surrounding  surface,  and  clotlied 
with  papilla;  which  branch  out  from  the  central  mass  without 
any  uniformity  of  arrangement.  Finally,  the  neoplasm  assumes 
the  form  of  a  soft  polyp,  covered  with  fringe-like  processes,  and 
attached  commonly  b}'  a  long,  slender  pedicle.  These  character- 
istics are  best  appreciated  by  floating  out  the  growth  in  water, 
when  the  individual  papillfe  become  very  apparent,  being  often 
an  inch  in  length,  and  bearing  a  striking  resemblance  to  the 
chorion,  or  often  imparting  to  the  affected  portion  of  the  bladder 
an  appearance  as  if  it  was  overlaid  witli  matted,  white,  soft 
fibres,  or  a  pile  of  loose  velvet,  as  in  the  annexed  drawing,  fig. 
29,  taken  from  a  preparation  in  the  pathological  collection  of  the 


Fio-.  39. 


P^pillaiy  Fibroma  of  llie  IiladUei'. 


I 


^ew  York  Hospital.     In  rare  instances  the  growth  is  incrusted 
with  a  deposit  of  phosphates. 

Tlie  usual  seat  of  villous  tumor  is  the  trigone,  particularly 
the  vicinity  of  the  orifices  of  the  ureters,  although  it  may  spring 


138 


TUMORS  AND  TUBERCLE  OF  THE  BLADDER. 


from  tlie  fundus,  anterior  wall,  or  neck  of  the  bladder,  in 
which  situation  it  may  overhang  the  opening  of  the  urethra  and 
act  obstructinglj.  Varying  in  size  from  a  pea  to  a  goose's  egg^ 
it  is  generally  solitary ;  but  it  may  occur  in  sucli  considerable 
numbers  as  to  overlay  the  greater  part  of  the  inner  surface  of 
the  viscus,  as  shown  in  tig.  80,  from  Civiale.     In  form  it  is 

Finr.  80. 


Multiple  Papillary  Fibroma  of  the  Bladder. 

generally  globose,  ovoidal,  or  polypoid,  while  its  color  is  usually 
a  few  shades  redder  than  that  of  the  surrounding  mucous  mem- 
brane. Contrary  to  the  conmion  statement,  the  disease  is  most 
frequent  in  middle-aged  and  elderly  subjects.  Thus  of  eighteen 
of  the  twenty  cases  in  wdiich  the  precise  age  was  noted,  the 
youngest  was  twenty-two  months,  and  the  oldest  seventy-two 
years ;  and  all  of  the  patients  save  three — aged  respectivel}' 
twenty -two  months,  thirty -three  months,  and  eighteen  years — 
were  over  thirty,  the  average  being  the  forty-fourth  year.  Sex 
appears  to  have  no  influence  upon  its  production,  as  ten  of  the 
cases  occurred  in  males,  and  an  equal  number  in  females. 

The  symptoms  of  papillary  Hbroma  are  frequent  and  often 
uncontrollable  desire  to  urinate,  the  act  being  difficult  and 
painful,  and  liable  to  occasional  interruption  of  the  tlow,  or 
positive  retention,  due,  when  the  growth  is  seated  at  the  neck 
of  the  bladder,  to  its  intrusion   into  the  vesical  orifice  of  the 


TUMORS  OF  THE  BLADDER.  139 

urethra,  or,  in  rarer  instances,  to  impaction  of  clots  in  tlie  canal. 
By  far  tlie  most  reliable  sign  is  hematuria,  Avhich  is  invariably 
present  at  some  stage  of  the  affection.  In  exceptional  instances  a 
little  blood  mixed  with  the  urine  is  the  earliest  symptom  ;  and  in 
ten  per  cent,  of  the  cases  a  sudden  hemorrhage,  coming  on  with- 
out assignable  cause,  the  loss  being  constant  or  subject  to  occa- 
sional remissions,  is  the  only  feature  from  first  to  last.  In  tlie 
majority  of  examples,  however,  it  is  preceded  by  signs  of  vesical 
irritability,  and  does  not  show  itself  until  the  affection  has 
existed  for  several  months.  The  blood  is  usually  mixed  with 
the  urine,  its  quantity  increasing  pari  passu  with  the  other 
symptoms ;  but  it  may  be  passed  in  its  pure  state  before,  or,  as 
more  often  happens,  at  the  completion  of  micturition,  when  the 
act  is  attended  wnth  great  straining. 

The  hemorrhage  in  these  cases  is  often  profuse,  and  from  its 
constant  recurrence,  it  is  the  most  fruitful  source  of  death. 
Tliat  the  villi  should  bleed  is  scarcely  to  be  wondered  at,  as 
their  enormously  dilated  vessels  are  being  constantly  laid  bare 
b}'  the  exfoliation  of  their  soft  and  delicate  epithelial  covering, 
a  process  which  is  favored  hy  the  irritation  of  the  decomposing 
urine,  thereby  exposing  them  to  insult  from  the  spasmodically 
contracting  hypertrophied  bladder.  Exploration  with  a  sound 
always  excites  bleeding  and  pain,  and  is  liable  to  be  followed 
by  retention. 

Suffering,  apart  from  that  experienced  in  connection  with 
micturition,  is  not  a  prominent  feature  of  the  disease.  Essential 
pain,  pain  connected  with  the  presence  of  the  tumor  itself,  was 
only  complained  of  to  a  severe  degree  by  three  patients,  and  it 
was  referred  to  the  h^-pogastrium  and  the  back. 

On  the  whole,  it  may  be  said  that,  in  the  absence  of  prostatic 
or  calculous  disease,  glandular  involvement,  and  carcinomatous 
cachexia,  the  existence  of  papillary  fibroma  is  rendered  highly 
probable  by  symptoms  of  vesical  irritability,  with  occasional 
attacks  of  retention  of  urine,  and  hematuria,  more  or  less  pro- 
fuse, as  a  constant  or  frequently  recurring  sign,  without  any 
obvious  cause.  Conclusive  evidence  of  its  true  nature  is  afforded 
1)}'  the  appearance  of  a  villous  growth  at  the  orifice  of  the 
urethra,  as  happened  in  the  case  of  a  young  girl,  or  by  the  dis- 
charge of  detached  vascular  tufts,  which  afford  the  minute 
appearances  previously  described.     Unless  the  groAvth  is  pedun- 


140  TUMORS    AXD    TUBERCLE    OF    THE    BLADDER. 

Ciliated,  or  contains  a  considerable  amount  of  solid  material, 
sounding  will  throw  no  light  upon  it. 

The  prognosis  of  this  aftection,  if  left  to  pursue  its  course 
without  surgical  interference,  is  of  the  worst  possible  descrii)tion, 
since  death  almost  invariably  follows  from  sheer  loss  of  blood, 
or  the  combined  effects  of  hemorrhage  and  pain.  A  further 
analysis  of  the  twenty  cases  shows  that  fourteen,  treated  merely 
by  palliative  measures,  were  fatal :  one  from  cholera ;  one  from 
uremia,  due  to  obstruction  of  the  ureters  by  clots  derived  from 
similar  growths  in  the  kidneys ;  three  from  the  exhaustion 
produced  by  suft'cring  and  loss  of  blood  ;  and  nine  from  hemor- 
rhage alone.  Of  the  remaining  six  cases,  to  which  reference 
will  again  be  made,  one  passed  the  growtli  during  an  act  of 
straining,  and  five  were  subjected  to  operations,  of  which  two 
recovered,  one  was  benefited,  and  two  died. 

The  morl)id  conditions  of  the  other  parts  of  the  urinary  tract 
refer  principally  to  hypertrophy  of  the  muscular  walls  of  the 
bladder.  In  a  few  instances  there  was  no  concomitant  disease 
whatever.  In  ten  the  viscus  was  more  or  less  hypertrophied, 
associated  in  two  with  great  contraction ;  in  one  with  abscess 
near  the  tumor ;  in  two  with  pyelitis ;  in  two  with  thickening 
and  dilatation  of  the  ureters  and  pelves  of  the  kidneys ;  and  in 
one  with  sacculation  of  the  bladder  and  villous  growth  of  the 
kidneys. 

y.  Polypoid  fibroma,  or  polj'p,  is  exceedingly  uncommon. 
Ordinarily  pyriform  or  globular  in  shape,  and  usually  attached 
by  a  narrow  pedicle,  it  is  either  smooth  and  even,  or  more  or 
less  lobulated,  at  its  peripher}',  and  made  up,  in  the  great  ma- 
jority of  instances,  of  lax,  succulent,  delicate  filamentous  tissue, 
or, more  rareh-,of  firm  interlacing  fibres.  It  is  poorh'  provided 
with  bloodvessels,  and  is  covered  by  a  reflection  of  the  vesical 
mucous  membrane,  the  cells  of  which  are  generally  normal, 
although  the}^  may  be  present  in  the  form  of  flat  tessellated  epi- 
thelium, in  immense  quantity. 

Excluding  the  cases  recorded  bj^  Lusitanus,  Kirchner,  Sjdvius, 
Rollin,  and  other  older  authors,  and  those  in  which  villous  hyper- 
plasia is  a  prominent  feature  of  the  growth,  fifteen  examples 
of  fibrous  polj'p  have  been  collected,  of  which  eight  occurred 
in  males,  and  seven  in  females,  their  ages  varying  from  thirteen 
months  to  fifty-six  years.     In  only  six  were  the  sul)jects  impubic. 


TUMOES    OF    THE    BLADDER,  141 

the  average  age  being  the  twentieth  year.  The  duration  of  the 
affection,  from  its  first  manifestation  until  its  close,  ranged  be- 
tween five  weeks  and  three  years,  the  average  being  fourteen 
weeks. 

These  tumors  occasionally  coexist  with  urinary  calculus,  or 
they  may  be  incrusted  with  crystals  of  triple  phosphates.  In  size, 
they  vary  from  a  pea  to  a  closed  fist,  and  they  are  usually  single, 
or,  if  multiple,  they  arise  either  at  several  distinct  points,  or  are 
clustered  on  a  common  pedicle.  They  evince  a  remarkable  pre- 
dilection for  the  neck  of  the  bladder,  near  the  orifice  of  the 
urethra,  not  less  than  nine  of  the  instances  having  had  their 
origin  at  that  locality,  the  remainder  having  developed  from  the 
fundus  of  the  organ.  In  a  case  narrated  by  Dr.  Willis,^  a  pen- 
dulous growth,  of  the  volume  of  a  cherry,  and  covered  with  cal- 
culous matter,  hung  from  the  anterior  wall  of  the  bladder,  so  as 
to  act  as  a  valve  at  the  urethral  opening. 

The  symptoms  of  vesical  polyp  are  chiefly  of  a  mechanical 
character,  the  most  prominent  being  difiiculty  in  urination,  sud- 
den stoppage  of  the  flow,  and  frequent  attacks  of  painful  reten- 
tion, owing  to  the  mass  obstructing  the  orifice  of  the  urethra, 
or  intruding  itself  into  it,  requiring,  in  exceptional  instances, 
the  daily  use  of  the  catheter.  Hemorrhage  is  very  infrequent, 
it  having  occurred  in  only  four  of  the  fifteen  cases,  in  three  of 
which  it  was  slight  and  recurred  at  long  intervals,  while  in  one  it 
was  occasioned  by  the  introduction  of  instruments.  In  two  boys, 
of  the  respective  ages  of  thirteen  and  eighteen  months,  in  addi- 
tion to  the  other  rational  signs,  reflected  pain  at  the  head  of  the 
penis,  which  is  so  characteristic  of  stone  in  children,  was  most 
marked.  In  all  of  the  females,  a  constant  and  extremely  valu- 
able symptom  was  protrusion  of  the  tumor  from  the  urethra  at 
the  vulva,  and  in  several  of  the  males  it  projected  into  the  pros- 
tatic portion  of  the  canal.  A  case,  recorded  by  Mr.  Stanley,^ 
deserves  especial  notice  in  this  connection.  In  consequence  of 
obstruction  of  the  urethra  by  the  morbid  growth,  attended  with 
frequent  attacks  of  retention,  the  urine  was  forced  into  the  im- 
perfectly closed  orifice  of  the  urachus,  which  gradually  reopened 
under  the  constant  pressure,  until  the  urine  reached  the  vicinity 

'  Urinary  Diseases  and  their  Treatment,  London,  1888,  p.  284. 
2  Trans.  Path.   Soc.   London,  vol.  iii.  p.  137 ;  aud  Med.  Times  and   GazeUe, 
1852,  vol.  ii.  p.  106. 


142     TUMORS  AND  TUBERCLE  OF  THE  BLADDER. 

of  the  uniljilicus,  whore  an  abscess  formed,  and  gave  exit  to  \ms 
and  urine,  upon  its  evacuation,  nine  days  before  death.  The 
patient  was  a  male  child,  thirteen  months  old,  who  had  presented 
symptoms  of  stone  for  ten  weeks.  On  dissection,  a  soft,  lobu- 
lated  growth  was  found  to  be  attached,  at  each  extremity,  by  a 
pedicle  to  the  bas-fond  of  the  bladder,  just  behind  the  ureters, 
which  were  dilated,  while  its  central  portion  could  be  propelled 
forwards  over  the  meatus  during  micturition. 

The  diagnosis  of  polypoid  fibroma  is  based  upon  the  foregoing 
symptoms.  From  other  tumors  it  is  distinguished  by  the  absence 
of  essential  pain,  and  by  difficulty  of  micturition,  as  the  earliest 
sj'mptom,  followed,  in  exceptional  instances.  In' hemorrhage.  It 
is  met  with  at  an  earlier  age  than  papillary  fibroma,  and,  unlike 
it,  the  bleeding  is  not  only  not  a  constant  sign,  but,  when  it 
does  occur,  it  is  of  trifiing  importance.  In  rare  instances,  as  in 
the  cases  of  two  children,  the  growth  can  he  felt,  enveloped  by 
the  contracted  bladder,  through  the  abdominal  walls.  This  does 
not  occur  in  villous  tumor.  From  calculus  it  may  be  dift'er- 
entiated  by  the  introduction  of  the  sound,  which  may  be  felt  to 
touch  the  growth,  but  does  not  elicit  a  metallic  note.  Instru- 
mental exploration  is  very  liable  to  be  attended  with  deviation 
of  the  beak  of  the  catheter  to  one  side  or  the  other,  and  it  may 
oven  be  impossible  to  carry  it  onwards,  so  that  lateral  move- 
ments are  impossible.  A  similar  phenomenon  is  witnessed  in 
hypertrophy  of  the  prostate,  but  the  latter  condition  may  be 
determined  by  a  digital  examination  though  the  rectum,  and  by 
the  advanced  age  of  the  patient.  In  females  a  protruding  polyp 
might  be  mistaken  for  eversion  of  the  bladder,  or  vascular  tumor 
of  the  urethra  ;  but  h\  careful  exploration,  and  tracing  the  mass 
with  the  finger  or  probe,  its  true  nature  is  readily  determined. 

The  prognosis  of  this  attection  is  most  unfavorable,  when  it 
is  not  opportunely  interfered  with,  a  fatal  issue  invariably  occur- 
ring from  retention  of  urine  and  its  eifects  upon  the  associated 
organs,  especially  the  kidneys.  In  the  cases  not  cured  by  opera- 
tion, the  principal  lesions  found  on  dissection  were,  dilatation 
of  the  urethra  and  neck  of  the  bladder,  with  hypertro|»hy  of 
the  muscular  coat  of  the  latter  viscus,  and  enlargement  of  the 
ureters  and  pelves  of  the  kidneys,  the  tissues  of  which  organs 
were  in  various  stages  of  inflammation. 

2.  Carcinomatous  Tumors. — Amono;  the  rarest  of  surgical  afiec 


TUMORS    OF    THE    BLADDER. 


14.^ 


tions  must  be  ranked  primary  carcinoma  of  the  bladder,  although 
it  is  not  very  uncommon  as  a  metastatic  deposit,  or  as  the  result 
of  the  extension  of  a  similar  growth  from  the  uterus  and  vagina 
in  the  female,  and  the  rectum  and  prostate  in  the  male.  Indeed, 
it  may  be  asserted  that  the  majorit}'  of  so-called  primary  cancers 
arise  from  proliferation  of  the  epithelial  elements  of  the  acini 
and  ducts  of  the  prostate;  its  connection  with  the  posterior  por- 
tion of  that  organ  being  proved  not  only  by  dissection,  but  by  its 
incomparably  more  frequent  occurrence  in  men  than  in  women. 

The  usual  variety  of  carcinoma,  met  with  in  the  bladder,  as 
shown  by  modern  histological  research,  is  the  epithelial.  What 
was  formerl}^  known  as  scirrhus  is  nothing  more  than  the  firm, 
infiltrating  form  of  epithelioma,  characterized  b}'  a  dense  stroma 
of  fibrous  tissue,  pervaded  by  small  and  infrequent  alveoli, 
which  contain  heaps  of  loose  epithelial  cells  and  epidermic 
pearls.  The  soft,  juicy,  medullary,  or  fungoid  form  of  tlie  afiec- 
tion,  generally  denominated  encephaloid,  is  of  the  same  nature, 
but  its  stroma  is  more  delicate  and  more  vascular,  and  the  loculi 
larger,  while  the  cells  are  the  seat  of  granular  and  fatty  metamor- 
phosis and  disintegration.  In  many  specimens,  the  latter  assume 
a  cylindrical  shape,  when  the  mass  presents  the  minute  appear- 
ances afforded  by  cylindrical  epithelioma  of  the  gastro- intestinal 
mucous  tract.    Other  varieties  of  carcinoma  are  almost  unknown. 

When  the  affection  has  existed  for  some  time,  the  overlying 
mucous  membrane  occasionally  be- 
comes the  seat  of  papillary  hyper- 
l)lasia,  the  delicate  prolongations  re- 
posing either  upon  an  unbroken,  soft, 
spongy,  elevated,  or  polypoid  tumor, 
or  upon  an  ulcerated  surface.  The 
connective  tissue  of  the  villi  becom- 
ing infiltrated,  by  continuous  growth 
from  below,  with  epithelial  cells,  poly- 
morphous, or  in  the  form  of  concentric 
]iearls,  or  cell  cylinders,  as  showm  in 
fig.  31,  reduced  from  Demme,  gives 
rise  to  the  so-called  "  villous  cancer," 
which,  from  its  macroscopic  resem- 
l)lance  to  papillary  fibroma,  has  been, 
and    is    yet,    generally    confounded         caiciaomatous  ve^.^ii  Papiiia. 


Fi-.  '.n. 


144    TUMORS  AXD  TUBERCLE  OF  THE  BLADDER. 

with  it.  It  is,  however,  far  less  common  than  the  henign  villous 
growth,  from  which  it  is  to  be  distinguished  by  the  iiitiltrated 
villi  reposing  upon  a  base  wdiich  shows  the  minute  features  of 
carcinoma,  and  by  the  proliferation  of  villi  into  the  main  mass. 

Epithelioma  is  observed  more  frequently  in  males  than  in 
females,  in  the  proportion  of  about  six  to  one,  and  is  almost 
peculiar  to  advanced  life,  being  most  common  betw^een  the  forty- 
fifth  and  eightieth  years,  occurring  very  rarely  before  the  fifth 
decade,  the  average  age  being  fifty-eight,  agreeing  in  this  respect 
with  the  disease  as  it  is  met  with  in  other  organs  of  the  body. 
The  parts  most  liable  to  be  aft'ected  are  the  neck,  trigone,  and 
bas-foud,  along  with  the  openings  of  the  ureters ;  and  it  is  seldom 
seen  at  the  summit  or  anterior  wall.  It  may  occur  as  a  circum- 
scribed solitary  tumor,  projecting  into,  and  almost  filling  up,  the 
bladder;  or  in  the  form  of  small  nodules,  from  the  volume  of  a 
pea  to  that  of  a  walnut ;  or  it  may  infiltrate  all  the  tunics  of 
the  viscus,  so  as  to  convert  them  into  a  dense  mass,  varying  in 
thickness  from  a  quarter  of  an  inch  to  two  inches;  or  form  a 
broad,  thick  belt  around  the  entire  circumference  of  the  bladder, 
from  its  neck  as  far  as  the  ureters,  as  in  the  case  of  a  gentleman, 
narrated  in  a  former  edition  of  this  w^ork.  The  tumor,  wdien  it 
is  of  long  standing,  wdiether  it  be  of  an  encephaloid  or  scirrhous 
appearance,  is  usually  in  a  state  of  advanced  ulceration,  and 
presents  a  foul,  ragged  surface,  several  inches  in  diameter ;  or 
the  ulcer  and  its  edges  are  beset  with  long  and  swollen  villous 
excrescences ;  or  it  may  be  simply  occupied  by  soft,  friable, 
l)roken-down,  pultaceous  material  and  clotted  blood. 

During  the  progress  of  the  disease,  the  associated  organs,  as 
the  prostate,  ureters,  and  kidneys,  are  liable  to  be  implicated, 
and  the  bladder  may  adhere  to  the  surrounding  parts,  and  com- 
municate with  the  vagina,  uterus,  rectum,  colon,  or  ileum.  The 
viscus  itself,  on  dissection,  is  usually  found  to  contain  a  small 
quantity  of  dark-colored,  fetid  urine,  mixed  w^ith  pus,  lymph, 
or  blood.  Sometimes  the  organ  is  very  much  contracted,  wdiile 
at  others  it  is  greatly  enlarged.  In  many  cases,  its  intermediate 
substance  is  healthy  ;  in  others  it  is  diseased  and  hypertrophied. 
The  ureters  and  .kidneys  are  also  now  and  then  aftected,  most 
commonly  dilated,  from  the  morbid  growth  plugging  up  the 
orifices  of  the  former,  thereby  causing  the  urine  to  accumulate 
in  their  interior,  and  occasion  death  from  uremia.     Secondary 


TUMORS    OF    THE    BLADDER.  145 

tleposits  are  found  in  about  one-half  of  the  cases  in  tlie  kidneys, 
liver,  iliac  and  lumbar  glands,  and  lungs,  in  the  order  here  men- 
tioned. 

Carcinoma  of  the  bladder  usually  runs  its  course  with  great 
rapidity,  death  ensuing  from  the  efiects  of  retention  of  urine, 
perforation  of  the  viscus,  infiltration  of  urine,  or  peritonitis,  on 
an  average  in  less  than  twelve  months.  Occasionally,  however, 
life  is  prolonged  for  eight  or  nine  yeai*s,  of  which  remarkable 
instances  are  recorded  by  Lambl,  Sir  Henry  Thompson,  and  Mr. 
W.  Michell  Clarke.  These  were  examples  of  villous  medullary 
epithelioma,  and  hemorrhage  was  a  prominent  symptom  from 
the  first. 

The  most  reliable  signs  of  epithelioma,  in  addition  to  those  of 
vesical  irritability,  are  pain,  hemorrhage,  and  constitutional 
cachexia,  Suflering  and  hematuria  are  present  in  at  least  three- 
fourths  of  all  cases,  the  former  being  often  of  the  most  excru- 
<'iating  character,  and  referred  to  the  hypogastrium,  perineum, 
loins,  and  testes.  In  a  noteworthy  instance  of  scirrhous  epithe- 
lioma, under  the  care  of  Dr.  John  Ashhurst,  the  specimen  of 
which  was  exhibited  at  the  Pathological  Society  of  Philadel- 
phia, in  the  fourth  volume  of  the  Transactions  of  which  body 
the  case  is  reported,  there  was  neither  pain  nor  hemorrhage  at 
any  stage  of  the  aftection,  the  immunity  from  suffering  being- 
ascribed  to  the  absence  of  ulceration.  It  is  to  be  remembered, 
however,  that  although  it  is  commonly  a  late  sjmiptom,  pain  is 
not  always  dependent  upon  an  open  state  of  the  growth,  since 
in  one-thiixi  of  the  cases,  in  which  suftering  was  complained  of, 
the  tumor  was  found,  on  dissection,  to  be  entire.  Hemorrhage, 
profuse  and  long-continued,  on  the  other  hand,  is  ascribable  to 
a  broken-down  or  ulcerated  state  of  the  morbid  mass,  or  to 
secondary  villous  formations  on  its  surface ;  but,  unlike  what 
occurs  in  the  ordinary  villous  growth,  although  it  may  be  a  most 
prominent  symptom,  it  never  exists  alone.  The  carcinomatous 
cachexia,  as  denoted  by  the  progressive  emaciation  and  loss  of 
strength,  and  the  wan  and  sallow  state  of  the  countenance,  is 
rarely  wanting  in  the  later  stages  of  the  disease. 

Additional  evidence  of  the  existence  of  carcinoma  may  be  eli- 
cited by  rectal  and  hypogastric  palpation,  and  the  sound,  and,  in 
thin  subjects,  the  enlarged  lymphatic  glands  may  be  felt  through 
the  abdominal  walls.  The  small  fragments  of  the  growth,  Avhich 
10 


145 


TUMORS    AXD    TUBEECLE    OF    THE    BLADDEE. 


are  occasionally  discharged  along  with  the  urine,  present,  after 
proper  hardening  and  section,  the  distinctive  features  of  carci- 
noma; or  if  minute  tufts,  which  represent  enlarged,  and  vascular, 
and  infiltrated  villi,  can  be  detected,  the  diagnosis  is  established 
beyond  the  possibility  of  a  doubt.  !N^ot  the  slightest  reliance 
can  be  placed,  as  was  so  often  done  before  the  prehistological 
period  of  morbid  growths,  in  the  cells  voided  with  the  urine,  as 
the  transitional  forms  of  epithelium  lining  the  genito-urinary 
tract,  particularly  those  of  the  second  and  third  rows  of  the 
bladder,  are  so  similar  to  those  of  carcinoma,  that  the  distinction 
is  impossible. 

Almost  the  only  affection  with  which  epithelioma  is  liable  to 
be  confounded  is  papillary  fil)roma,  or  villous  growth.  For  the 
purpose  of  pointing  out  their  differential  diagnosis,  their  charac- 
teristics are  given  in  the  subjoined  table: — 


Epithelioma.  . 

1.  Is  a  disease  of  elderly  persons,  the 
average  age  being  the  fifty-eighth  year. 
Never  occurs  in  children. 


rapillary  fibroma. 

1.  Au  affection  of  adult  life,  the 
average  age  being  the  forty-fourth  year. 
Ten  per  cent,  of  cases  met  with  in  im- 
pubic  subjects. 

2.  Sex  exerts  no  influence  upon  its 
production. 

3.  Pain  in  onl}'  fifteen  per  cent,  of 
cases. 

4.  Hemorrhage  of   constant   occur- 


2.  ^lost  common  in  males. 

3.  Pain  present  in  seventy-five  per 
cent,  of  cases. 

4.  Hemorrhage  in  seventy-five  per 
cent,  of  cases.    Usually  a  late  symptom,  ;  rence,  and  often  at  outset  without  ob- 
aud  never  the  only  one.  .  yious  cause.     In  rare  cases  the  only 

'  symptom  throughout. 

5.  May  be  detected  by  the  sound,  and  !      5.  Eludes   digital  and   instrumental 
manual  exploration  of  the  rectum  and    examination, 
hypogastrium. 


6.  Never  protrudes  at  the  vulva. 

7.  Discharged  fragments  show  car- 
cinomatous structures. 

8.  Carcinomatous   cachexia    late  in 
the  disease. 

9.  Lymphatic   involvement  may  be 
detected  bj'  palpation  of  al)domen. 

10.  The  affection  terminates  fatally, 
on  an  average,  in  twelve  months. 


6."  Maj-  appear  at  this  point. 

7.  Discharged    fragments   show 
epithelial  proliferation. 

8.  No   sucli    appearance   in   villous 
growth. 

9.  The  glands  of  pelvis   and   loins 
never  contaminated. 

10.  Fatal  result  seldom  earlier,  on 


an  average,  than  three  years. 

3.  Sarcomatous  T'^o/iors.— Sarcoma  of  the  bladder,  as  verified 
by  the  microscope,  is  so  rarely  met  with  that  it  is  impossible  to 
give  a  satisfactory  account  of  its  clinical  features.  It  is  quite 
certain,  however,  that  many  neoplasms,  reported  as  encephaloid 


TUMORS  OF  THE  BLADDER.  147 

cancer,  occurring  before  the  fortieth  year,  and  composed  of 
small  round  cells,  closely  packed  in  a  homogeneous,  or  finely 
granular,  or  imperfectly  fibrillated,  intercellular  sul)stance, 
should  be  classified  under  this  head  ;  and  it  is  highly  probable 
tliat  tumors  have  been  included  under  polypoid  and  villous 
growths  which  were  composed  of  sarcomatous  tissue.  It  may 
be  stated,  in  a  general  way,  that  sarcoma  occurs  earlier  in  life 
than  papillary  fibroma  and  epithelioma ;  that  it  shows  little 
tendenc}^  to  bleed,  even  when  subjected  to  surgical  interference ; 
and  that  it  is  attended  with  symptoms  of  obstruction  of  the 
flow  of  urine,  without  being  the  seat  of  essential  pain. 

Dr.  Gersuny'  has  given  the  details  of  the  case  of  a  man,  forty- 
nine  3'ears  of  age,  in  which  a  firm,  elastic,  lobulated  spindle- 
celled  tumor,  of  the  volume  of  a  hen's  egg,  was  attached  by  a 
long,  delicate  pedicle  to  a  diverticulum  at  the  base  of  the  blad- 
der, where  it  had,  for  five  years,  excited  symptoms  of  vesical 
irritability  and  retention  of  urine,  requiring  the  constant  use 
of  the  catheter.  The  growth  could  be  felt  by  the  sound  and 
the  finger  in  the  rectum.  A  fatal  attempt  was  made  to  remove 
it  by  median  cystotomy ;  but  it  might  have  been  reached  through 
the  bowel. 

An  example  of  pedunculated  round-celled  sarcoma  of  the 
bladder,  associated  with  similar  disease  of  the  vagina  and 
vesico-vaginal  septum,  is  recorded  by  Mr.  Marcus  Bedc  in  the 
twenty-fifth  volume  of  the  Transactions  of  the  Pathological 
Society  of  London.  A  child,  two  years  of  age,  suffered  from 
incontinence  and  attacks  of  pain  and  straining  on  micturition, 
followed  by  slight  bleeding.  TAvelve  months  previously,  six 
small  polyps  had  been  removed  by  the  ligature  from  the  vagina. 
A  mass  of  growths,  some  of  which  were  as  large  as  grapes,  pro- 
jected from  the  urethra,  distending  it  so  Avidely  that  it  was  at 
first  mistaken  for  the  vagina.  Death  occurred,  without  further 
interference,  from  exhaustion,  sixteen  months  from  the  com- 
mencement of  the  disease.  The  bladder,  on  dissection,  was 
found  to  be  hypertrophied,  and  the  tumors  sprung  from  the 
thickened  mucous  membrane  of  its  neck  and  bas-fond. 

A  most  instructive  instance  of  spindle-celled  growth  has  been 
reported  by  Dr.   Senftleben,^  from    the    practice  of    Professor 

'  Laugenbeck's  Arcliiv.,  Bd.  xiii.  1872,  p.  131. 
2  Ibid.,  Bd.  i.  1861,  p.  128. 


148  TUMORS    AND    TUBERCLE    OF    THE    BLADDER. 

Langenbeck.  A  woman,  twent3--nliie  years  of  age,  had  been 
troubled  with  dysuria  aud  incontinence  for  fourteen  months, 
and  during  forcible  eftbrts  to  empty  the  bladder  and  rectum  a 
red,  fleshy  mass  protruded  from  the  widely  dilated  urethra 
Avhich  she  was  in  the  habit  of  snipping  off,  the  operation  being 
attended  with  neither  pain  nor  hemorrhage.  Attempts  to 
tear  away  the  tumor  with  forceps  were  useless,  on  account  of 
its  great  friability.  Death  ensuing  from  peritonitis  on  the 
fourth  day,  a  firm,  elastic,  villous  growth,  of  the  size  of  a 
walnut,  was  found  to  originate  from  the  intermuscular  connec- 
tive tissue  of  the  neck  of  the  bladder,  the  base  of  that  viscus 
having  been  perforated  by  the  forceps. 

The  treatment  of  tumors  of  the  bladder  is  palliative  and 
radical.  The  former,  which  has,  as  a  rule,  alone  been  resorted 
to,  consists  in  allaying  pain  and  spasm,  by  anodynes,  in  full  and 
repeated  doses,  and  in  preventing  and  arresting  hemorrhage, 
which  is  so  troublesome  a  complication.  To  fulfil  the  latter 
indication,  everything  tending  to  favor  a  determination  of 
blood  to  the  pelvic  organs,  as  riding,  prolonged  exercise  on  foot, 
warm  hip  baths,  and  venereal  indulgence,  sbould  be  scrupulously 
avoided.  The  bowels  should  be  maintained  in  a  soluble  condi- 
tion, and  the  diet  should  be  nourishing,  and  consist  of  such 
articles  as  are  not  productive  of  flatulence  and  dyspepsia. 
When  bleeding  has  once  set  in,  our  main  reliance  is  upon  opium 
and  acetate  of  lead,  gallic  acid,  and  alum,  with  acidulated  drinks, 
and  rest  in  the  recumbent  posture,  with  elevation  of  the  pelvis. 
In  a  case  of  villous  tumor,  under  the  care  of  the  author,  prompt 
relief  was  always  afforded  by  a  dose  of  calomel  and  rhubarb, 
followed  by  alum  and  opium,  with  sulphuric  acid  and  infusion 
of  roses  as  a  common  drink.  A  highly  eflicacious  combination, 
is  ten  drops  each  of  turpentine  and  dilute  sulphuric  acid,  with 
five  grains  of  gallic  acid,  administered  every  few  hours.  AVhen 
the  ordinary  remedies  fail,  a  drop  of  creasote,  given  in  the  form 
of  emulsion,  every  two  hours,  also  proves  servicable,  as  do  also 
the  tincture  of  ergot,  and  the  solution  of  pernitrate  of  iron. 
The  action  of  these  medicines  is  promoted  by  the  application  of 
ice  bags  to  the  hypogastrium  and  perineum,  and  a  conical  plug 
of  ice  introduced  into  the  rectum,  vagina,  or  even  the  bladder, 
sometimes  acts  like  a  charm.     Direct  medication,  in  the  form 


TUMORS    OF    THE    BLADDER.  149 

of  astringent  injections,  such  as  solutions  of  acetate  of  lead,  alum, 
g-allic  acid,  persulphate  of  iron,  ergotine,  and  nitrate  of  silver, 
should  be  cautiously  resorted  to  in  obstinate  cases.  It  is  of  the 
last  importance  to  remember  that,  when  the  hemorrhage  is  at 
all  troublesome,  it  is  usually  due  to  the  hypertrophied  bladder 
contracting  down  upon  a  villous  or  ulcerated  growth,  to  j^revent 
which,  the  patient  should  be  taught  to  relieve  the  organ  with  a 
soft  catheter,  in  order  that  he  may  retain  at  least  an  ounce  of 
urine. 

For  the  relief  of  papillary  and  polypoid  fibromas  surgical  in- 
terference is  imperatively  demanded,  since,  without  it,  a  fatal 
issue  is  almost  the  inevitable  result.  Among  the  earlier  ope- 
rations in  this  direction  are  those  of  Civiale,^  in  which  the 
tumor  was  seized  and  torn  away  with  the  trilabe,  or  crushed  by  a 
lithotrite,  and  left  to  drop  oft*  and  be  spontaneously  discharged, 
or  be  extracted  several  days  subsequently.  Although  the 
French  surgeon  reports  many  successes,  his  practice  does  not 
appear  to  have  gained  any  followers.  In  male  subjects  the  only 
rational  mode  of  attacking  these  growths  is  by  opening  the 
1)ladder,  and  removing  them,  in  accordance  with  the  extent  of 
their  attachments,  by  enucleation,  avulsion,  scraping,  ^crase- 
raent,  or  ligation.  In  females,  on  the  other  hand,  cystotomy  is 
generally  uncalled  for,  since  on  account  of  the  greater  shortness 
and  dilatability  of  the  urethra,  and  the  absence  of  the  prostate, 
access  to  the  tumor  is  rendered  easy,  and  attended  with  less  risk. 

That  the  bladder  may  be  opened,  when  it  contains  a  new 
growth,  with  a  pretty  fair  prospect  of  success,  is  attested  not 
only  by  formal  operations  practised  for  their  removal,  but  by 
several  recorded  instances,  in  which,  under  the  belief  that  the 
patients  were  affected  with  calculous  disease,  cystotomy  was 
resorted  to.  Mr.  Crosse,  of  ISTorwich,  under  these  circumstances, 
disclosed  a  mass  of  polj'poid  excrescences,  as  soon  as  the  mem- 
l)ranous  urethra  was  opened,  which  were  removed  with  the 
scissors,  but  the  child,  which  was  much  prostrated  by  previous 
suftering,  died  in  forty-four  hours,  after  uncontrollable  vesical 
tenesmus.  Petit,^  of  Lyons,  cut  a  man,  twenty-eight  years  of  age, 
and  discovering  the  presence  of  a  tumor,  decided  that  nothing 

'  Traite  Pratique  sur  les  Maladies  des  Organs  Genito-Urinaires,  1860,  t.  iii 
pp   151-175. 

2  Med.  du  Coeur  et  Discours,  etc.,  p.  340. 


150  TUMORS    AND    TUBERCLE    OF    THE    BLADDER. 

more  was  to  be  done.  On  death  from  phthisis,  one  year  afterwards, 
a  pyriform  polyp,  with  a  very  delicate  pedicle,  and  as  large  as 
the  fist,  was  found  to  occupy  the  bladder.  There  are,  moreover, 
at  least  three  examples  of  operations  for  stone,  which  were  com- 
plicated by  the  existence  of  morl)id  growths,  and  they  were  all 
snccessful.  In  one,  Desault  removed  the  calculus,  and  twisted 
off  the  tumor ;  Avhile  in  two,  which  occurred  to  Deschamps, 
and  the  author,  the  stones  were  extracted,  but  the  neoplasms 
were  not  interfered  with.  The  latter  case  was  that  of  a  lad, 
tifteen  years  of  age,  who  was  greatl}^  emaciated,  and  was  almost 
worn  out  by  constant  suffering.  A  large  phosphatic  concretion 
was  removed  by  the  lateral  incision,  at  the  Clinic  of  the  Jeffer- 
son Medical  College,  in  the  winter  of  1874,  and  the  anterior 
wall  of  the  bladder  was  felt,  by  vesical  and  hypogastric  palpa- 
tion, to  be  the  seat  of  a  sessile,  lobulated,  firm,  elastic  tumor, 
which  was  probably  of  a  myomatous  nature. 

In  the  male,  the  best  mode  of  reaching  these  groAvths,  particu- 
larly if  the}^  be  at  all  voluminous,  is  by  epicystotomy.  To  gain  as 
much  room  as  possible,  Billroth,  after  having  first  verified  the 
diagnosis  bj^  opening  the  bladder  through  the  perineum,  cut  the 
recti  muscles  at  their  insertions,  and  incised  the  bladder  trans- 
versely. A  portion  of  the  tumor  was  torn  away,  and  the  re- 
mainder tied  and  dissected  off'  from  the  muscular  coat,  in  which 
it  originated.  Two  arteries  were  ligated  and  the  threads 
l)rouo;ht  out  at  the  upper  wound.  To  guard  against  infiltration 
of  urine,  the  wound  in  the  bladder  was  not  approximated,  but  a 
drainage  tube  was  passed  through  the  organ,  and  allowed  to 
hang  out  of  the  lower  opening.  The  reaction  was  moderate, 
and  the  boy  was  discharged  on  the  thirty-second  day,  a  truss 
having  been  adjusted  to  prevent  hernial  protrusion. 

In  females,  under  similar  circumstances,  the  bladder  may  be 
reached  above  the  pubes  ;  but  if  a  cutting  ojDeration  be  decided 
upon,  it  will  be  best  to  confine  it  to  a  median  incision,  com- 
mencing at  the  posterior  orifice  of  the  urethra  and  terminating 
at  a  level  with  the  ureters,  through  the  vesico-vaginal  septum. 
An  opening  of  this  size  will  readily  admit  the  introduction  of 
two  fingers  and  the  interior  of  the  organ  can  be  dragged  into 
view  by  inserting  double  hooks  into  the  mucous  membrane 
at  each  side  of  the  incision.     On  the  completion  of  the  operation, 


TUMORS    OF    THE    BLADDER. 


151 


Fi?.  32. 


the  edges  of  the  wound  should  be  brought  together  by  the 
shotted  wire  suture,  to  guard  against  the  formation  of  a  fistule. 
When  the  tumor  protrudes  at  the  female  urethra,  as  usually 
happens,  a  ligature  should  be  passed  through  its  substance,  and 
a  stout  wire  passed  over  it,  by  means  of  a  double  canula,  when, 
b}'  making  traction  on  the  tliread,  the  loop  can  be  slipped  down 
to  its  attachment,  and  strangulation  be  eftected.  At  the  expira- 
tion of  forty-eight  hours,  the  mass  may  be  removed  by  giving 
the  canula  a  few  twists,  which  is  far  preferable  to  allowing  it  to 
slough  off  spontaneously.  In  other  cases,  as  in 
the  majority  of  villous  growths,  which  only 
exceptionally  occur  as  pedunculated  growths, 
it  will  be  necessary  to  dilate  the  urethra,  and 
the  more  rapidly  this  is  done,  the  less  risk  will 
there  be  of  subsequent  incontinence  of  urine. 
For  this  purpose  the  thoroughly  anaesthetized 
l^atient  is  placed  in  the  lithotomy  position, 
and  the  hard  rubber  cylindrical  specula  of  Pro- 
fessor Simon,  of  Heidelberg,  are  successively 
introduced,  with  a  rotary  motion  and  without 
force.  The  set  consists  of  seven  numbers,  of 
which  jSTo.  1  corresponds  with  IS'o.  27  of  Char- 
riere's  catheter  scale,  and  has  a  diameter  of  nine 
millimetres ;  'No.  2  of  eleven  mm. ;  and  so  on 
up  to  IS'o.  7,  the  diameter  of  which  is  two  centi- 
metres, or  four-iifths  of  an  inch.  The  annexed 
drawing,  fig.  32,  represents  No.  5  of  its  natural 
size.  The  introduction  of  the  largest  instru- 
ment is  scarcely  possible  without  the  previous 
nicking  of  the  urethral  orifice  with  the  bistoury, 
in  several  directions.  On  removing  the  ob- 
turator the  growth  is  fairly  exposed,  and  can 
be  strangulated,  cut,  scraped,  or  torn  away,  as 
may  he  deemed  proper.  In  this  way  Professor 
Simon  has  succeeded  in  scraping  off  papillary 
fibromas,  by  means  of  a  sharp  spoon-shaped  instrument,  the 
bowl  of  which  is  bent  at  a  right  angle  with  the  shaft ;  and  he 
declares  that  in  upwards  of  fifty  cases,  in  which  he  has  resorted 
to  this  mode  of  dilatation,  either  for  diagnostic  or  therapeutical 
purposes,  not  only  was  there  no  subsequent  incontinence,  but 


SimOQ's    Uieihral 
Speculum. 


152    TUMORS  AND  TUBERCLE  OF  THE  BLADDER. 

the  bladder  was  capable  of  retaining  water  thrown  into  it  imme- 
diately after  the  withdrawal  of  the  speculum. 

Previous  to  subjecting  the  patient  to  a  cutting  operation,  it 
would  be  well  to  imitate  the  practice  of  Dr.  Mass,  of  Breslau,' 
which  consists  in  pouring  water  into  a  double-ein^rent  catheter 
inserted  in  the  bladder,  and  relying  on  its  rapid  outward  flow 
to  entangle  the  growth  in  the  eye  of  the  instrument.  In  this 
way,  I)r.  Mass  succeeded,  in  three  adult  males,  in  removing 
small,  pedunculated  mucous  polyps. 

The  following  table  exhibits  the  statistics  of  sixteen  operations 
for  the  removal  of  vesical  growths.  It  will  be  seen  that  six  were 
fatal ;  two  in  males  after  cystotomy  ;  and  four  in  females,  one 
from  avulsion,  and  three  from  ligation,  the  latter  being  children, 
in  whom  surgical  measures  hold  out  little  prospect  of  relief,  on 
account  of  the  multiplicity  of  the  tumors,  thereby  rendering 
them  inaccessible,  unless  by  suprapubic  incision.  Of  nine  adult 
females,  all  recovered  save  one,  death  in  this  instance  being  duo 
to  peritonitis  from  perforation  of  the  bladder  by  tlie  forceps  in 
attempts  to  tear  away  a. sarcomatous  polyp. 

•  Berl.  Klin.  Wochschft.,  Jan.  24,  1876. 


TUMORS    OF    THE    BLADDER. 


153 


3      :z 

oT        T3 

c^ 

&. 

,r 

d. 

j£_ 

eu 

M 

,_■ 

_i     pa     ^ 

a 

'c;     S     si 

1       6 

ee 
o 

CO 

:= 

CO 

:=■ 

3 
< 

"o 

X 

X 

x 

O 

tD        oo          _. 

c-5 

B. 

(» 

A 

13 

ri 

CO 

CO                  IM 

So2 

.2                ''' 

;!    2 

ri 

TS 

._ 

'      M 

pa 

pa 

'-5 

—            — 

o 

c 

is  > 

-      P5 
.-        o 

>* 

-6  'i 

la 

3 
CO     . 

o             S 

9) 

5g^ 

5  "^  J 

<U            i. 

s    < 

-< 

< 

_  O 

a  1-1 

>               00 

Pi 

c'c:  J° 

ggiS^^ 

«        -d 

a      .■" 

M 

."' 

ci         01                .        1 

OO^ 

t- 

to 

^ 

^ 

Ji! 

"^ 

==          _■ 

^    !*>5J 

1     S 

CO 

3 

a       o 
o        » 

<D 

s 

JJ  o 

i-a        pa 

■^    b  -= 

.3 

4) 

02 

•-5^-2 

,a 

-a 

■^5 

ci   c    c 
a;  ._   1- 
>-   u   to 

—    ^  —    »  'S     • 

5          _g;5 

S 

e^  a 

^   If: 

a 

.  a  " 

1     .> 

Hp   p 

fiS^  p  i^  o 
5     i-i     S 

1  r 

d 

o 

iC  a  '^  c3 

,-.  a  L, 
ci 

c 
c: 

^|S 

a           "o 

<1        hi 

o 

a 

< 

iJ 

1-3 

i-a 

pq 

i-a        <; 

J= 

^ 

_^ 

>• 

'3 

>         ? 

a      ^       i> 

O          (M           O 

.-   o   r 

ci 

a 

o 

IS 

01 

a 

S 

2      & 

1      i 

=      §      t 

.2       a       g 

r-      ^      *" 

'^  a  £ 

o  o  ^ 

CO 

a 

o 

;« 
o 

o 

c 

CO 

"&) 

a 

c3 

6 
1^2 

o 

cS 
CO 

c 

a 

3 

o 

CO 

J  =  -§  *  ,^ 

o     a,     !z; 

o 

ft 

ci 

^ 

"3 

IT—   o 

o 
a 
< 

5  .SP 
o-'S 

a  •  -  S  -=  £ 

a       Si 

c 

.M 

Im 

c 

o 

0) 

o 

>. 

-ij         J3         *j 

3          SO 

= 

B 

a 

1     fe 

—       a 

0) 

a 

a 

C 

a 

o 

s 

a, 
O 

3          O         "« 

a       'Ji: 

a 

o 

: 

z 

o     o 

Q    5    S 

a     Oi 

n 

&" 

5 

i-s 

a       J     1 

>% 

>> 

;;^ 

0) 

3 

,n 

>                      J3 

> 

5 

cS 

°         -           ~ 

;!        - 

O 

o 

- 

- 

= 

- 

- 

- 

-          rt 

f^ 

<u 

Q 

9 

Q> 

3 

t».      >% 

>>     — 

a     a 

a     = 

c 

<D 

O    g    o 

o         ? 

o 

o 

s°s 

11  ^g 

A 

^•r^  ^ 

>>—  2  .2 

ta 

a 

Cm 

o    o    « 

o   3   P  '3 

o 

o 

^-  — -  — 

•5§5Sg 

a 

a           a 

T3 

5 

_o 

O  *s         o 

'm    a        *m 

-^  a>       f— 1 

o 

.-.    C- 

.Z  c  o  s  a 

tS 

"a 

S    9          S 

1^ 

s  =*  fe 

PL,     eti 

PM        »       1-^ 

CO 

> 
< 

a. 

&I 

o 

rt 

e3 

>. 

o 
a 

a 

o 

p, 

a 

o 

Cu 

a. 

1^ 

5 

f->         ti 

_ -M                f^ 

>> 

^ 

_>. 

o              « 

o  a               — 

^ 

J 

a            3 

o 

s 

1 1 

S        M2 

<^3-      a 
1  s  s  ^   - 

rt  -T!  c  a      r:: 

-J    ®    3    O          — 

o 
c 

3 

o 

: 

: 

>> 

'a. 

: 

:: 

3 
O 

=            o 

1     i 

O                  o 

^ 

z      S     S 

£ 

1^ 

tf 

£ 

>               DQ 

o 

^ 

0 

;-<           ^ 

M 

>. 

;      >^ 

a 

>% 

■< 

M            OS 

C^           lO 

<N          CO 

CO 

-^ 

IT 

o 

o 

■* 

O 

O               OS 

■* 

c-q        ^7 

(M 

•o 

■^ 

i~ 

•^ 

_3L 

'^ 

to             M 

01 

s    ^ 

S     S     fe 

fa      p^ 

^ 

tci 

(i 

Em 

Es^ 

f^ 

Pm 

^          Eci 

OQ 

-    - 

C>J 

c<- 

'i' 

urs              50 

O 

1-1       N 

??      •*      »o 

O         tr- 

00 

Oi 

^ 

;zi 

^" 

~ 

" 

" 

" 

154  TUMORS    AXD    TUBERCLE    OF    THE    BLADDER. 

Sect.  II.— TUBERCLE  OF  THE  BLA.DDER. 

The  bladder,  particularly  its  neck,  bas-fond,  and  vicinity  of 
the  ureters,  is  sometimes  the  seat  of  tubercular  disease,  occurring 
in  the  form  of  minute  gray  or  cheesy,  spherical  or  rounded 
nodules,  of  a  semiconcrete  consistence,  scattered  in  the  super- 
ficial layer  of  the  mucous  membrane,  and  surrounded,  while  in  a 
crude  state,  by  delicate  vascular  areas.  After  these  bodies  have 
existed  for  an  indefinite  period,  they  coalesce,  soften,  and  are 
finally  entirely  broken  down,  leaving  in  their  stead  so  many 
roundislj,  circumscribed  ulcers,  the  bases  and  ragged  and  under- 
mined edges  of  which  have  a  yellowish  appearance,  due  to  their 
infiltration  with  gray  and  cheesy  miliar}"  tubercles,  as  is  shown 
b}'  minute  examination.  By  the  confluence  of  several  small 
ulcers,  larger  secondary  ones  are  produced  ;  and  not  infrequently 
to  §uch  an  extent  as  to  destroy  the  greater  portion  of  the  mucous 
membrane. 

Tubercle  of  the  bladder  is  invariably  associated  Avith  a  similar 
deposit  in  other  parts  of  the  body,  and  is  usually  the  result  of 
extension  of  the  disease  from  the  prostate  or  seminal  ducts,  or, 
as  more  rarely  happens,  from  the  kidneys  or  ureters,  on  which 
account  it  is  rarely  met  with  in  females.  In  the  case  of  a  woman, 
twenty-four  years  of  age,  under  the  care  of  the  author,  in  1854, 
along  with  almost  universal  destruction  of  the  mucous  coat,  there 
was  extensive  infiltration  of  the  right  ureter  ;  the  corresponding 
kidney  Avas  tlie  seat  of  a  tubercular  abscess  ;  the  Fallopian  tubes 
were  filled  with  strumous  pus  ;  the  left  ovary  contained  a  solitary 
crude  deposit ;  the  rectum  and  lower  portion  of  the  colon  were 
covered  with  ulcers ;  the  lungs  contained  numerous  tubercles ; 
and  a  few  of  the  bronchial  glands  were  invaded  hy  the  disease. 
Its  coexistence,  however,  with  tuberculosis  of  the  lungs  is  un- 
common. 

In  six  cases,  the  details  of  which  are  given  in  the  last  edition 
of  this  work,  the  bladder  was  more  or  less  extensively  ulcerated, 
the  mucous  membrane  in  several  of  them  being  completely 
destroyed,  and  the  muscular  fibres,  thickened,  and  even  fascicu- 
lated, as  neatly  dissected  as  if  it  had  been  done  by  the  anatomist. 
The  kidneys,  one  or  both,  were  tuberculated  in  every  instance ; 
the  ureters  suftered  in  four,  and  the  urethra  in  two.  In  two  of 
the  cases  there  was  tubercle  of  the  prostate,  and  in  one  of  the 


TUBEECLE    OF    THE    BLADDER.  155 

seminal  vesicles.  The  lungs  were  affected  in  two  cases  ;  and  the 
lymphatic  glands  of  the  pelvis  were  involved  in  one  instance, 
and  the  bronchial  glands  in  another.  One  of  the  patients  had 
psoas  abscess,  one  iliac  abscess,  and  one  recto-vesical  abscess. 

There  are  no  symptoms  which  point  definitely  to  the  existence 
of  this  affection.  Before  softening  takes  place,  there  is  merely 
a  slight  degree  of  vesical  irritability;  but  when  ulceration  has 

■  set  in,  the  prominent- signs  are  a  frequent  and  gradually  increas- 

ling  desire  to  urinate,  with  more  or  less  pain  in  performing  the 
act.     The  urine  is  purulent  and  generally  bloody,  or  pure  l)lood 

I  may  be  passed  at  the  completion  of  micturition.  The  ema- 
ciation is  progressive,  and  death  is  always  preceded  by  hectic 

I  fever,  and  occasionally  by  exhausting  diarrhoea.  Tubercle  of 
the  bladder  is  a  disease  of  young  adults,  the  average  age  being 
twenty-six  j^ears ;  and  destroys  life  in  from  one  to  two  years. 

The  treatment  consists  in  the  administration  of  tonics,  cod- 
liver  oil,  iodine,  and  anodynes,  along  with  a  nutritious  diet 
and  recumbenc3\  Should  the  suffering  be  acute,  and  the  bladder 
be  intolerant  of  the  presence  of  a  small  quantity  of  fluid,  it  may 

'  be  opened  through  the  perineum,  so  as  to  afford  an  escape  for 
the  urine  as  fast  as  it  is  secreted.  In  the  female,  the  affected 
portion  of  the  mucous  membrane  may  be  brought  into  view  by 
Simon's  specula,  and  be  pencilled  over  with  a  strong  solution 
of  nitrate  of  silver. 


OHATTER  YII. 

VARIX  AND  HEMORRHAGE  OF  THE  BLADDER. 

Sect.  I.— VARIX  OF  THE  BLADDER. 

Varicose  enlargement  of  the  vesico-prostatic  plexus  of  veins 
was  described  by  some  of  the  older  writers  under  the  term 
hemorrhoids,  in  reference  to  the  resemblance,  real  or  fancied, 
which  it  occasionally  bears  to  hemorrhoids  of  the  anus  and 
rectum.  It  is  rare,  however,  that  the  disease  is  so  well  defined 
as  to  entitle  it  to  such  an  appellation.  In  the  seventeenth  and 
eighteenth  centuries,  the  affection  received  the  special  attention 
of  Bonetus  and  Morgagni,  who  have  each  left  some  well-marked 
examples  of  it. 

Although  the  disease  occurs  most  commonly  in  old  age,  it  is 
sometimes  observed  at  a  comparatively  earl}-  period,  especially 
in  persons  Avho  have  been  long  aftlicted  with  stone  in  the  blad- 
der, stricture  of  the  urethra,  hypertrophy  of  the  prostate  gland, 
or  organic  disease  of  the  anus  and  rectum.  The  enlargement 
may  be  circumscribed  or  diffused,  according  to  the  number  of 
vessels  implicated  in  the  disease,  and  it  ma^y  present  itself  in 
various  degrees,  from  the  slightest  increase  in  the  size  of  the 
affected  vessels  to  the  most  remarkable  dilatation.  In  the  more 
confirmed  forms,  the  veins  are  not  only  much  augmented  in 
volume,  but  they  have  a  tortuous,  convoluted  arrangement, 
similar  to  what  occurs  in  varix  of  the  leg  and  thigh.  When 
thus  aftected,  their  walls  are  always  more  or  less  thickened 
from  interstitial  deposits,  and  their  cavities  are  occupied  by 
fibrinous  concretions.  The  connective  tissue  through  which  the 
enlarged  vessels  ramify  is  also  materiallj'  increased,  forming  not 
infrequently  a  thick,  dense  mass,  divisible,  especially  along  the 
bas-fond  of  the  bladder,  into  a  number  of  layers.  While  these 
changes  are  going  on  upon  the  exterior  of  the  organ,  a  similar 
but  less  conspicuous  enlargement  occasionally  takes  place  within 
at  the  neck  and  most  dependent  portion  of  the  body  of  the  viscus. 


VARIX    OF    THE    BLADDER.  157 

The  disease  here  consists  either  in  a  simple  varicosity,  or  in 
the  development  of  vascular  growths,  not  unlike  hemorrhoidal 
tumors,  hoth  in  their  structure,  color,  and  consistence.  Such 
tumors,  however,  are  uncommon ;  they  seldom  exceed  the  A^olume 
of  a  small  fill:»ert,  and  are  usually  situated  near  the  neck  of  the 
bladder.  In  general,  they  are  associated  with  other  diseases, 
particularly  stone,  which,  no  doubt,  often  acts  as  an  exciting- 
cause. 

The  influence  of  mechanical  obstruction  in  causing  varix  of 
the  bladder  is  rendered  very  apparent  by  the  fact  that  the  disease 
is  amost  invariably  associated  with  stone  in  the  bladder,  obstruc- 
tion to  the  evacuation  of  the  urine,  and  organic  aifections  of  the 
anus  and  rectum.  The  current  of  the  blood  being  thus  habitu- 
ally interrupted,  the  distended  vessels  become  gradually  dilated 
and  tortuous,  as  well  as  seriously  changed  in  their  structure  from 
the  eltects  of  chronic  inflammation,  the  inseparable  concomitant 
of  such  a  condition. 

There  are,  unfortunately,  no  symptoms  bj'  which  this  disease 
can  be  distinguished  from  other  atiections.  Its  existence  must 
always  be  a  matter  of  inference  rather  than  of  positive  demon- 
stration. A  person  may  be  supposed  to  be  laboring  under  it 
when,  if  he  has  stone  in  the  bladder,  stricture  of  the  urethra,  or 
hypertrophy  of  the  prostate  gland,  he  has  frequent  attacks  of 
hemorrhage,  venous  in  its  character,  not  profuse,  and  attended 
with  a  sense  of  weight  low  downi  in  the  pelvic  region.  The 
enlarged  vessels,  under  such  circuuTstances,  sometimes  give  way, 
especially  during  straining  and  the  introduction  of  instruments, 
although  the  bleeding  is  seldom  either  profuse  or  protracted. 
Bonetus'  describes  a  case  where  a  disease  of  this  kind  simulated 
stone  in  the  bladder.  The  patient  at  length  died,  when  no  cal- 
culus was  discovered,  but  the  veins  around  the  neck  of  the  organ 
were  varicose  and  very  much  distended  with  blood.  In  the  sec- 
tion on  hemorrhage  of  the  bladder  will  be  found  the  particulars 
of  a  case,  observed  by  Professor  Laugier,  of  Paris,  in  which  tlie 
bleeding  was  so  abundant  as  to  prove  fatal. 

When  the  existence  of  varices  is  suspected,  relief  should  be 
attempted,  first,  by  the  removal  of  the  exciting  cause  of  the 
disease,  and  secondly,  by  the  application  of  leeches  to  the  peri- 

'  Scpulchrum.  lib.  iii.  sec.  xxv.  p.  263. 


loS        VARIX    AXU    HEMORKHAGE    OF    THE    BLADDER. 

neo-anal  region,  the  cold  douche,  the  frequent  introduction  of 
cold  water  or  lumps  of  ice  into  the  rectum,  and  the  use  of  mild 
laxatives,  with  rest  in  the  recumbent  posture.  All  heating  and 
drastic  cathartics  must  be  avoided,  an  account  of  their  tendency 
to  stimulate  the  lower  bowel,  and  thus  invite  a  determination 
of  blood  to  the  affected  parts.  For  the  same  reason  diuretics 
should  be  interdicted,  especially  the  different  preparations  of 
cantharides.  The  manner  in  which  the  hemorrhage,  consequent 
upon  a  division  of  these  vessels,  is  to  be  arrested,  will  be  pointed 
out  under  the  head  of  lithotomy. 

The  hemorrhage  which  occasionally  attends  this  -aftection 
should  be  controlled,  if  possible,  by  the  exhibition  of  gallic  acid, 
acetate  of  lead,  creasote,  and  other  appropriate  remedies  ;  aided 
by  injections  of  cold  water  into  the  rectum,  and  the  application 
of  ice  to  the  perineum  and  hypogastrium. 

Sect.  II.— HEMORRHAGE  OF  THE  BLADDER. 

The  presence  of  blooyd  in  the  urine,  technically  denominated 
liematuria,  is  not  of  very  frequent  occurrence  in  vesical  afte(.'- 
tions.  The  blood  may  be  derived  from  any  portion  of  the 
genito-urinary  mucous  tract ;  or  it  may  be  symptomatic  of  other 
afi^ections.  Hence,  it  is  not  always  easy  to  draw  a  distinction 
between  hemorrhage  dependent  upon  causes  resident  in  the 
bladder,  and  causes  which  act  on  some  other  portion  of  the 
urinary  apparatus. 

Vesical  hemorrhage  occurs  in  both  sexes  and  all  periods  of 
life.  Men,  however,  are  more  prone  to  it  than  women,  and  it  is 
likewise  more  common  in  middle-aged  and  advanced  subjects,  of 
a  weak,  lax  habit  of  body,  than  in  children  and  young  adults. 
It  occurs  in  association  with,  or  as  a  consequence  of,  purpura, 
scurvy,  rubeola,  smallpox,  plague,  and  typhoid  fever,  or  as  a 
symptom  of  compression  of  the  ascending  colon,  from  cirrhosis 
of  the  liver,  or  other  obstructing  causes.  The  bleeding  may  be 
vicarious  of  the  menstrual  flow  and  suppressed  hemorrhoidal 
discharges;  and  a  considerable  loss  of  blood  occasionally  results 
from  the  use  of  drastic  cathartics  and  irritating  diuretics,  espe- 
cially cantharides  and  oil  of  turpentine,  which  occasion  acute 
congestion  of  the  vesical  mucous  membrane. 

The   traumatic   form  of  hemorrhage  is  usually  the  result  of 


HEMORRHAGE    OF    THE    BLADDER.  159 

injuries  from  a  blow,  fall,  or  kick,  or  of  a  wound,  such,  for 
instance,  as  is  made  in  the  operation  of  lithotomy;  or  of  the 
rude  or  forcible  use  of  instruments,  as  the  lithotrite,  sound,  or 
catheter.  Persons  affected  with  stone  are  very  liable  to  suffer 
from  vesical  hemorrhage,  especially  after  rough  exercise  in  a 
carriage  or  on  horseback.  "Worms,  accidentally  lodged  in  the 
bladder,  have  been  known  to  cause  profuse  and  even  fatal  loss  of 
blood.  Venereal  excesses,  violent  concussion  of  the  body,  and 
severe  exercise  on  horseback,  may  be  enumerated  as  among  the 
more  common  causes  of  the  atfection.  Van  Swieten^  records 
the  case  of  a  riding-master,  who,  soon  after  an  attempt  to  break 
a  stubborn  horse,  discharged  not  less  than  eight  pounds  of  blood 
in  a  few  hours. 

Ulceration  of  the  bladder  is  nearly  always  accompanied  by 
bleeding;  and  one  of  the  most  characteristic  signs  of  papillary 
fibroma  and  open  carcinoma  of  the  viscus  is  a  persistent  and 
considerable  hemorrhage,  wdiich  is  liable  to  be  aggravated  by 
examinations  with  instruments. 

Varices  of  the  bladder  occasionally  give  rise  to  hemorrhage; 
sometimes  slight,  at  other  times  copious;  now  of  short  duration, 
now  long-continued.  An  instance  occurred  at  the  IIotel-Dieu 
in  Paris,  in  the  service  of  Professor  Laugier,^  in  which  the  bleed- 
ing w^as  so  profuse  as  to  prove  fatal.  The  patient,  who  had  some 
time  previously  labored  under  acute  myelitis,  ^vith  paraplegia, 
had  been  in  the  house  several  days,  on  account  of  a  bou}'  tumor, 
when  the  attack  came  on.  The  blood  was  of  a  dark  color,  and 
was  voided  perfectly  pure,  ■svithout  any  admixture  of  urine. 
Catheterism  failed  to  detect  any  appreciable  lesion  in  the  bladder, 
which  was  much  distended,  and  pushed  high  up  into  the  abdomen. 
The  hemorrhage  continued  to  recur  at  intervals,  sometimes 
slightly,  at  other  times  copiously,  until  the  man  sunk  from 
exhaustion.  The  autopsy  revealed  the  existence  of  several 
large  varices  at  the  neck  of  the  bladder,  upon  one  of  which  was 
a  large  ulcer,  from  which  the  bleeding  had  evidently  proceeded. 
The  organ  was  perfectly  sound  in  other  respects. 

A  peculiar  form  of  hemorrhage  of  the  bladder,  indigenous 
to  Egypt  and  Africa,  and  probably  of  dietetic  origin,  is  the 
endemic   hematuria    which   depends   upon   the   presence  of  an 

'  Comment  in  Aph.  Pat.,  1422,  p.  251. 
2  Gaz.  des  Hop.,  No.  81,  1854,  p.  321. 


160        VARIX    AND    HEMORRHAGE    OF    THE    BLADDER. 

entozooii,  known  as  the  Bilharzia  Hematobin,  in  the  small  veins 
of  the  mncous  and  other  tissues  of  the  organ.  At  the  points  in 
which  the  eggs  of  the  worm  are  embedded,  the  lining  membrane 
is  congested  and  ecchymosed.  The  ova  and  embryos,  as  well  as 
the  fully-developed  parasites,  can  be  detected  in  the  urine  and  in 
the  blood  which  usually  flows  after  the  bladder  is  emptied. 
Sometimes  small  clots  or  bloody  mucus,  presenting  the  same 
characteristics,  are  discharged. 

When  recently  effused  into  the  empty  bladder,  tlie  blood  is  of 
a  natural  appearance;  but  if  it  has  been  retained  for  some  time, 
or  been  diii'used  through  the  urine,  it  assumes  a  smoky,  or  dark- 
brownish  hue,  not  unlike  porter,  or  the  sediment  of  beef-tea. 
In  some  instances,  especially  when  it  is  pent  up  for  a  long  time, 
it  is  of  the  color  of  tar  or  molasses.  It  is  generally  liquid  when 
the  discharge  is  recent,  but  coagulated  when  it  is  of  several  hours' 
standing.  Complete  coagulation  seldom  takes  place,  except  in 
the  traumatic  form  of  the  affection,  in  connection  with  an  empty 
or  partially  empty  bladder.  These  changes  in  the  color  and 
consistence  of  the  effused  blood  are  owing  to  the  chemical  action 
of  the  urine  on  the  blood  corpuscles.  When  the  urine  is  neutral 
or  alkaline,  the  color  is  of  a  florid-red;  but  when  the  reaction  is 
acid,  it  is  of  a  smoky  or  browniish  tint. 

The  most  important,  because  the  most  characteristic  symptom 
of  vesical  hemorrhage,  is  a  discharge  of  blood  from  the  urethra, 
citlier  alone  or  in  combination  with  the  urine,  and  accompanied, 
if  the  quantity  be  at  all  considerable,  by  a  frequent  desire  to 
micturate,  spasm  at  the  neck  of  the  bladder,  and  a  burning  sen- 
sation along  the  course  of  tlie  urethra.  When  the  blood  coagu- 
lates nearly  as  fast  as  it  is  poured  out  l)y  the  bladder,  it  may 
lead  to  retention  of  urine,  either  partial  or  complete,  temporary 
or  permanent.  Copious  eft'usions  of  this  kind  may  be  followed, 
sooner  or  later,  by  all  the  symptoms  of  exhaustion. 

Hemorrhage  of  the  bladder  is  liable  to  be  mistaken  for  hemor- 
rhage of  the  kidneys,  the  ureters,  prostate  gland,  and  urethra ; 
and  it  need,  therefore,  hardly  be  added  that  the  diagnosis  is 
sometimes  difficult,  if  not  impracticable.  In  case  of  direct 
injury  of  the  bladder  by  Avound,  calculus,  or  instrument,  there 
need  be  no  room  for  doubt.  The  nature  of  the  lesion  is  suffi- 
ciently obvious.  In  the  idiopathic  form  of  the  hemorrhage, 
hoAvever,  great  uncertainty  must  frequently  exist.     Under  such 


HEMORRHAGE    OF    THE    BLADDER.  161 

circumstances,  the  history  of  the  case,  and  the  absence  of  disease 
or  injury  of  the  associated  organs,  may  assist  in  clearing-  up  tlie 
difficulty,  and  leading  to  a  correct  diagnosis. 

When  the  bleeding  proceeds  from  the  kidneys,  it  ma3Mlepend 
upon  external  injury,  temporary  congestion,  inflammation,  cal- 
culi, carcinomatous,  sarcomatous,  or  villous  tumors,^  parasites, 
and  tubercle  ;  or  it  may  be  s^-mptomatic  of  cold,  miasm,  and 
certain  constitutional  disorders,  as  purpura  and  the  eruptive 
fevers.  The  blood  is  usually  intimately  mixed  with  the  urine, 
imparting  to  it  a  smoky  tint ;  while  the  urine  itself  has  an  acid 
reaction,  and  contains  blood  casts.  Pure  blood  ma}'  follow 
laceration  of  the  kidney,  with  rupture  of  the  renal  artery ;  or  a 
few  drops  may  pass,  after  the  discharge  of  clear  urine,  in  villous 
disease,  which  has  only  been  met  with  in  old  subjects,  and  in 
which  the  passage  of  clots  along  the  ureter  may  produce  symp- 
toms that  are  indistinguishable  from  those  due  to  the  passage 
of  a  renal  calculus.  Malignant  growths  are  characterized  by 
the  presence  of  a  prominent  lobulated  tumor  in  the  loin,  usually 
of  the  right  side,  and  rapid  breaking  down  of  the  general  health. 
Intermittent  or  paroxysmal  hematuria,  which  is  due  to  tempo- 
rary congestion  of  the  vessels  of  the  Malpighian  bodies,  from 
exposure  to  cold  or  malaria,  is  marked  by  the  rapidity  with 
which  blood  appears  in  the  urine,  after  an  attack  of  shivering 
or  feeling  of  chilliness.  The  urine  is  acid,  little  disposed  to 
decompose,  of  a  deep  claret  or  porter  color,  and  deposits  a  dark 
sediment,  which  consists  principally  of  hematin  granules,  few, 
if  any,  blood  corpuscles,  urea,  and  granular  casts.  When  the 
hemorrhage  depends  upon  the  presence  of  the  Bilharzia  Ilema- 
tobia,  the  ova  and  embryos  may  be  detected  in  the  urine.  Acute 
and  chronic  albuminous  nephritis  are  marked  by  dropsy,  and 
scanty  and  smoky  urine,  which  contains  epithelial  cells,  casts, 
and  cylinders,  and  hyaline,  blood,  granular,  and  fatty  casts. 
From  whatever  cause  it  may  arise,  the  bliseding  is  liable  to  be 
preceded  and  accompanied  by  symptoms  referable  to  the  kidneys, 
such  as  aching,  heat,  and  pain  in  the  loins,  and  retraction  of 
the  testes. 

Hemorrhage  of  the  ureters  is  generally  produced  by  the 
presence  of  a  calculus,  the  passage  of  which  lacerates  the  vessels 

'  Trans.  Path.  Soc.  of  London,  vol.  xxi.,  1870,  pp.  239-244. 
11 


162       VAKIX    AXD    HEMORRHAGE    OF    THE    BLADDER, 

of  their  lining  meniljrane,  and  gives  rise  to  sudden  and  violent 
pain,  extending  to  the  back,  groins,  inside  of  the  thighs,  and  end 
of  the  penis,  intermittent  in  its  character,  and  attended  with 
retraction  of  the  testes,  distressing  nausea,  vomiting,  cold  sweats, 
and  a  sense  of  excessive  prostration,  and  even  faintness.  The 
passage  of  coagiila  may  also  give  rise  to  a  paroxysm  of  nephritic 
colic. 

In  vesical  hemorrhage,  the  larger  portion  of  the  blood  is  dis- 
charged tow^ards  the  completion  of  micturition,  or  a  moderate 
quantity  of  florid  blood  is  passed  after  the  last  drops  of  urine. 
If  it  depends  upon  a  calculus,  the  amount  is  increased  after 
rough  exercise,  and  exploration  with  the  sound  usually  suflices 
to  establish  the  diagnosis;  wdiile  if  it  is  due  to  a  parasite,  the 
ova  and  embryos  may  be  detected  in  the  urine.  The  loss  of 
blood  from  a  papillary  iibroma  is  a  constant  or  frequently  recur- 
ring symptom  without  any  obvious  cause,  unless  a  fragment  of 
the  growth  can  be  detected  in  the  urine,  and  is  usually  preceded 
by  signs  of  vesical  irritability.  The  blood  is  generally  mixed 
with  the  urine,  or  is  passed  in  a  liquid  state  at  the  completion 
of  micturition ;  although,  in  exceptional  instances,  it  may  flow^ 
before  the  urine.  Hemorrhage  from  inflammation  or  ulceration 
of  the  bladder  is  characterized  by  the  usual  symptoms  of  these 
affections,  and  the  coincident  discharge  of  pus  and  mucus. 

In  chronic  prostatitis,  the  passage  of  blood  wnth  the  last  drops 
of  urine,  along  with  cylindrical  moulds  of  pus-containing  mucus, 
and  tenderness  on  rectal  ex})loration,  suffice  to  determine  the 
diagnosis. 

Urethral  hemorrhage  is  generally  produced  by  acute  inflam- 
mation, instrumental  contact,  external  violence,  the  passage  of 
a  calculus,  or  the  venereal  orgasm  ;  and  the  blood,  whether  it 
be  fluid  or  clotted,  precedes  the  discharge  of  urine.  It  should, 
how^ever,  be  remembered,  that  in  hemorrhage  of  the  urethra,  the 
blood  may  regurgitate  into  the  bladder,  Avhere,  uniting  wdth  the 
contents  of  that  viscus,  it  may  assume  the  aspect  and  consistence 
which  belong  to  the  blood  of  vesical  hemorrhage.  In  excep- 
tional cases  of  villous  tumors  seated  at  the  neck  of  the  bladder, 
pure  blood  may  precede  the  urine. 

A  source  of  the  discharge  of  blood  from  the  urethra,  as  rare 
as  it  is  interesting,  is  laceration  of  the  deferent  duet,  of  which 
occurrence  Mr.  Hilton  lias  met  with  three  examples.'     After  a 


HEMORRHAGE    OF    THE    BLADDER.  163 

violent  strain  or  blow,  something  was  felt  to  give  way  in  the 
right  groin,  which  was  accompanied  with  immediate  pain,  and 
at  once  followed  by  a  flow  of  blood  from  the  nretlira.  The 
introduction  of  the  catheter  showed  the  urine  to  be  perfectly 
clear ;  and  a  day  or  two  afterwards,  each  patient  had  a  tender 
swelling  of  the  spermatic  cord  in  the  inguinal  canal. 

Great  assistance  in  the  diagnosis  of  hematuria  may  be  derived 
from  the  inspection  of  any  clots  that  may  be  passed,  to  which 
particular  attention  has  been  directed  by  Mr.  Hilton.^  By 
floating  out  the  coagula  in  water,  so  that  they  may  unravel,  they 
will  be  seen  to  have  assumed  the  configuration  of  the  part  in 
which  the  blood  was  effused.  In  this  way  they  form  moulds  or 
casts  of  the  pelvis  of  the  kidne}^  and  ureter.  Of  the  latter  occur- 
rence, a  noteworthy  example  is  recorded  by  Dr.  Hyde  Salter.^ 
The  cylindrical  clot,  which  was  mistaken  for  a  worm,  was  six 
inches  long,  pointed  at  each  extremity,  and  coiled  u|». 

In  a  remarkable  case,  recorded  by  Dr.  T.  B.  Reed,*  large 
quantities  of  worm-like  clots,  from  two  and  a  half  to  three  and 
a  half  inches  in  length,  by  one  or  two  lines  in  diameter,  were 
passed  during  an  attack  of  acute  nephritis.  The  blood,  however, 
was  of  renal  origin,  as  demonstrated  by  post-mortem  inspection, 
and  coagulated  in  the  ureter,  the  lumen  of  which  was  constricted 
by  coagulated  blood,  the  result  of  rupture  of  the  kidney,  encir- 
cling its  exterior. 

Vesical  clots  are  distinguished  by  their  irregular  circular  and 
flattened  shape,  and  bevelled  and  serrated  edges.  Long,  per- 
fectly round  coagula,  passed  before  the  urine,  indicate  hemor- 
rhage of  the  urethra  anterior  to  its  prostatic  portion.  Clots 
from  the  latter  locality  are  of  a  leech-like  or  ovoid  configuration 
in  their  long  axis. 

In  the  treatment  of  vesical  hemorrhage,  attention  must  be 
paid  to  the  nature  of  the  exciting  cause,  which  must  necessarily, 
in  all  cases,  exert  a  controlling  influence  in  regard  to  our  thera- 
peutic agents.  In  the  traumatic  variety,  the  ordinary  hemos- 
tatics are,  of  course,  indicated,  and  should  be  emplo^-ed  without 
delay.      When  the   bleeding  depends  upon  the  presence  of  a 

'  Gu}''s  Hosp.  Rep.,  vol.  xiii.,  1867,  p.  24. 

2  Ibid.,  pp.  19-28. 

3  Trans.  Path.  Soc.  Loud.,  vol.  xi.  p.  164,  and  plate  4,  fig.  8. 
^  Tiaus.  Path.  Soc.  Pliilada.,  vol.  v.,  1876,  p.  142. 


164       VARIX    AND    HEMORRHAGE    OF    THE    BLADDER. 


foreign  body,  it  sliould  be  removed.  Papillary  fibroma  sliould 
be  reached  by  cystotomy,  or,  in  the  female,  by  rapid  dilatation 
of  the  urethra.  If  an  operation  be  deemed  undesirable  in  this 
form  of  hemorrhage,  or  in  idiopathic  bleeding,  palliation  alone 
is  attempted.  The  most  important  remedies,  of  which  a  full 
account  is  given  at  page  148,  are  recumbency,  cutting  off  the 
supply  of  drinks,  milk  diet,  opium,  acetate  of  lead,  gallic  acid, 
tincture  of  ergot,  tincture  of  the  chloride  of  iron,  and  cold  appli- 
cations to  the  perineum,  h^-pogastrium,  or  a  lumj)  of  ice  inserted 
into  the  rectum.  Tlie  catheter  is  carefully  avoided.  Should 
retention  of  urine  ensue,  the  treatment  is  that  laid  down  at 
page  115. 


CHAPTER    VIII. 

STONE  IN  THE  BLADDER. 

Sect.  I.— NATURE  AND  CAUSES. 

Most  urinary  calculi  originate  in.  tlie  kidneys,  from  which 
they  descend  into  the  bladder,  where,  if  they  are  retained  for 
any  length  of  time,  they  gradually  increase  in  size,  and  ulti- 
mately produce  more  or  less  obstruction.  The  elements  of  the 
urine,  on  the  other  hand,  may  be  precipitated  in  the  bladder,  in- 
stead of  in  the  secreting  substance  of  the  kidney* ;  or  they  may 
aggregate  around  a  foreign  substance  in  the  bladder.  When  the 
calculus  has  a  nucleus  of  uric  acid  or  oxalate  of  lime,  the  proba- 
bility is  that  it  had  a  renal  origin;  but  vesical,  if  it  is  phosphatic. 

Stone  in  the  bladder  occurs  at  all  periods  of  life,  from  the 
most  tender  infancy  to  the  most  decrepid  old  age.  Indeed,  there 
is  reason  to  believe  that  it  occasionally  exists  as  an  intrauterine 
affection,  of  which  Langenbeck  met  with  an  example  in  a  six 
months'  male  foetus.^  Geyer^  relates  the  case  of  a  boy  who  suf- 
fered from  calculus  of  the  bladder  from  birth.  He  was  cut  in 
his  twelfth  year,  when  the  stone  had  acquired  so  large  a  bulk 
tliat  it  had  to  be  broken  before  it  could  be  extracted.  The  whole 
mass  weighed  ten  ounces.  StahP  found  a  calculus  of  the  size  of 
a  peach-kernel  in  an  infant  of  three  weeks  that  had  suffered 
great  distress  from  its  birth  in  passing  its  water.  Similar  ex- 
amples are  mentioned  by  Kicolai,  Armstrong,  Richel,  Greding, 
Xosaus,  ISTorris,  and  others. 

That  calculous  disorders  are  most  common  in  young  subjects, 
however,  may  be  seen  from  the  subjoined  statistics,  which  show 
that  more  than  one-third,  or  40  per  cent.,  occur  before  the  tenth 
year,  and  more  than  one-half,  or  58  per  cent.,  before  the  twentietli 
year.  The  disease  is,  therefore,  most  common  in  infancy,  child- 
hood, and  adolescence. 

'  Coulson,  Diseases  of  the  Bladder  and  Prostate  Gland,  p.  418.  London,  1857. 
2  Miscel.  Nat.  Curios.  Dec.  11,  An.  V.  p.  456. 
*  Diss.  De  Morb.  Fcetunm  in  Utero  Materno.  S.  6. 


166 


STOXE    IX    THE    BLADDER. 


Table  showing  the  ages  of  8574  Calculous  Patients. 


English 
Hospitals.) 

Sarahunpore 
Dispensary. - 

Penn'a 
Hospital.' 

Moscow. 

Clviale.' 

Total. 

From   1  to  10  years, 

815 

294 

38 

305 

2046 

3498 

••     10  "  20      " 

289 

123 

18 

115 

943 

1488 

"    20  "  30      " 

97 

150 

9 

33 

460 

748 

"    30  ''  40      " 

89 

102 

6 

11 

230 

438 

"    40  "  50      " 

108 

81 

5 

3 

391 

588 

"    r,0  "  60      " 

213 

55 

3 

8 

413 

685 

"    GO  "  70      " 

178 

16 

1 

577 

773 

"     70  "  80      " 

37 

2 

299 

338 

"     80  "  90      '• 

1 

1 

17 

19 

1827 

824 

78 

469 

5376 

8574 

111  attem[)tiiig  to  form  a  correct  estimate  of  the  relative  fre- 
quency of  vesical  calculus  in  cliildren,  adults,  and  old  persons, 
we  must  not  lose  sight  of  the  fact  that  many  of  the  cases  which 
fiill  into  the  hands  of  the  surgeon  are  examples  of  long  standing, 
extending,  perhaps,  through  a  period  of  many  years.  Thus,  it 
often  happens  that  a  youth  of  fifteen  is  cut  for  a  stone  developed 
in  infancy  ;  that  a  person  of  twenty-five  has  carried  a  calculus 
since  the  age  of  ten  ;  and  that  an  old  man  has  a  stone  which 
hegan  to  form  in  middle  life.  Indeed,  it  may  be  assumed,  as  a 
general  rule,  that  a  number  of  years  usually  intervene  between 
the  manifestation  of  the  first  symptoms  of  stone  in  the  bladder 
and  the  extraction  of  the  same  stone  by  operation.  Moreover,  it 
should  be  borne  in  mind  that  calculous  diseases  are  more  frequent, 
in  certain  countries,  among  children  than  among  adults,  and 
conversely.  Thus,  the  greater  number  of  stone  cases  in  AVirtem- 
berg,  in  the  mountains  of  Switzerland,  the  ISTeapolitan  States, 
and  in  some  of  the  counties  of  England,  especially  Xorfolk, 
occurs  in  young  persons,  from  causes  hitherto  unexplained.  In 
Kentucky,  lithotomy  is  performed  much  more  frequently  upon 
children  under  fifteen  years  of  age  than  upon  adults. 


'  Sir  Henry  Thompson,  Practical  Lithotomy  and  Lithotrity,  3d  ed.,  p.  375. 
The  table  includes  the  lateral  operations  of  lithotomy  practised  at  the  Norwich, 
Oxford,  Birmingham,  Guy's,  St.  Thomas's,  University,  and  Addenbrooke's 
Hospitals,  and  the  Leicester  and  Leeds  Infirmaries. 

2  Dr.  Garden,  Indian  Annals  of  Medical  Science,  No.  xxiii.,  1868,  p.  20. 

3  Dr.  ;Morton,  Pennsylvania  Hosp.  Rep.,  vol.  ii.  pp.  42-43. 

<  The  cases  embraced  in  Civiale's  list  occurred  in  France,  Austria,  Bavaria, 
Bohemia,  Dalmatia,  Saxony,  Denmark,  Lombardy,  Egypt,  and  other  countries. 


•NATURE    AND    CAUSES.  167 

Certain  facts  seem  to  warrant  the  inference  that  this  affection 
is  hereditary.  Thus,  Civiale  relates  the  case  of  a  man  on  whom 
he  practised  lithotrity  whose  mother  had  had  stone,  and  one  of 
whose  children  died  of  it.  He  also  performed  the  operation  on 
two  brothers,  whose  grandfather  and  two  uncles  had  labored 
under  the  disorder.  Prout  speaks  of  a  family  in  which  the  : 
father,  son,  and  grandson  were  all  afiected  with  uric  acid  calculi. 

It  has  been  long  known  that  calculous  diseases  are  much  more  , 
common  among  the  poor  than  the  rich.  This  remark  is  true, 
there  is  reason  to  believe,  of  these  two  great  divisions  of  society 
in  all  parts  of  the  world  where  these  complaints  prevail.  Upon 
what  this  difterence  depends  is  not  positively  ascertained ;  but 
the  probability  is,  that  it  is  mainly  due  to  derangement  of  the 
digestive  organs,  engendered  by  the  use  of  unwholesome  food, 
by  irregular  habits,  want  of  cleanliness,  intemperance,  and  defi- 
cient clothing. 

Vesical  calculus  does  not  occur  with  equal  frequency  in  all 
countries.  Thus,  in  the  United  States,  it  is,  so  far  as  is  at 
present  known,  by  far  more  common  in  Kentucky,  Virginia, 
Tennessee,  and  Ohio,  than  in  any  other  portions  of  the  Union. 
Missouri,  Indiana,  Maryland,  Pennsylvania,  and  I^orthern 
Alal)ama,  also  furnish  a  considerable  number  of  cases.  On 
the  other  hand,  calculous  disorders  are  comparatively  infrequent 
in  Xew  York,  Georgia,  the  two  Carolinas,  Florida,  Louisiana, 
Mississippi,  Arkansas,  Iowa,  Wisconsin,  Illinois,  Texas,  Mexico, 
and  California.  In  iSTew  Jersey,  Delaware,  and  the  iSTew  England 
States  generally,  stone  in  the  bladder  is  proverbially  rare.  The 
malad}"  is  also  uncommon  in  Canada  and  the  other  British 
Provinces  of  Xorth  America.  The  causes  of  these  differences 
have  not  been  ascertained  ;  attempts  have  been  made  to  trace 
them  to  the  effects  of  climate,  and  to  the  influence  of  the  water, 
food,  and  hal^its  of  the  people,  but  without  success. 

With  regard  to  the  influence  exerted  by  race  upon  the  pro- 
duction of  stone,  our  information  is  meagre.  The  disease  is 
very  common  among  the  rice-eating  natives  of  India;  and  the 
reports  of  the  resident  missionary  physicians  show  that  the 
Chinese  are  not  so  exempt  from  it  as  was  formerly  supposed. 
The  different  varieties  of  the  negro  race  of  this  country  are 
much  less  subject  to  vesical  calculus  than  the  whites.  In  a 
former  edition  of  this  work,  I  scave  a  table  of  the  relative  fre- 


168  STOXE    IX    THE    BLADDER. 

quency  of  stone  amon^  the  Avliite  and  colored  residents  of  the 
United  States,  whicli  was  based  upon  443  cases  of  lithotomy, 
occurring  in  Kentucky,  Virginia,  Tennessee,  Georgia,  Alabama, 
Louisiana,  and  Missouri,  from  which  it  appears  that  only  63,  or 
14.22  per  cent,  of  operations  were  practised  on  the  negro  and 
mulatto,  while  six  times  that  number  were  done  in  whites. 

In  Egypt  Professor  Reyer  states  that  the  disease  is  unknown 
in  the  negro  race,  while  it  is  very  prevalent  among  the  Arabs  ; 
q,nd  it  would  appear,  from  the  writings  of  Dr.  Livingstone,  that 
the  negroes  of  Central  Africa  are  entirely  free  from  the  aiiection. 

LTrinary  calculi  are  much  more  frequent  in  men  than  in  women, 
in  the  proportion  of  about  20  to  1,  because,  in  the  first  place, 
they  are  more  constantly  exposed  to  the  exciting  causes  of  the 
complaint,  and  atiections  which  obstruct  the  ready  flow  of  the 
urine ;  and  second!}',  because  of  the  more  complicated  structure 
of  the  urinary  apparatus,  which  prevents  the  read}'  discharge  of 
sabulous  matter,  and  thus  favors  the  formation  of  stone.  But 
for  the  latter  circumstance,  the  probability  is  that  young  girls 
would  sufl['er  nearly  as  often  as  boys. 

AVhat  influence,  if  any,  occupation  exerts  upon  the  production 
of  this  disorder,  we  have  no  statistical  facts  to  determine.  In 
Ohio,  and  in  the  southwestern  States,  especially  Kentucky  and 
Tennessee,  the  great  majority  of  calculous  subjects  are  common  . 
laborers,  farmers,  and  mechanics,  or  the  sons  of  persons  of  this 
description  ;  and  the  same  is  true,  I  suppose,  of  the  calculous 
cases  in  the  other  States.  Persons  who  are  habitually  exposed 
to  cold  and  wet  are  said  to  be  particularly  prone  to  this  com- 
plaint ;  the  fact,  however,  if  it  be  one,  requires  confirmation 
before  it  can  be  received  as  true.  Seataring  people  are  remarkably 
exempt  from  urinary  calculi,  and  a  similar  immunity  seems  to 
be  enjoyed  by  soldiers. 

Climate,  doubtless,  exercises  no  little  influence  in  the  forma- 
tion of  urinary  concretions.  It  has  been  already  stated  that,  in 
the  United  States,  this  disease  is  most  common  in  Ohio,  Kentucky, 
Tennessee,  and  Virginia  ;  a  circumstance  which,  so  far  as  is 
known,  does  not  depend  upon  any  peculiarity  of  living,  and  which 
may  therefore  be  supposed  to  be  owing  to  some  mysterious  opera- 
tion of  the  climate.  In  Holland,  calculous  disorders  are  very 
common,  and  the  circumstance  is  the  more  remarkable  because  | 
of  the  great  use  tliat  is  made  there  of  gin,  which  is  a  powerful    j 


NATURE    AND    CAUSES.  169 

diuretic.  That  this  liquor  is  not  the  cause  of  this  occurrence  is 
proved  by  the  fact  that  the  Dutch  colonists  of  Batavia,  in  the 
island  of  Java,  whose  habits  are  not  at  all  dissimilar  from  tliose 
of  the  people  of  the  mother  country,  are  almost  entirely  exempt 
from  this  affection.  Soemmering  states  that  the  disease  is  alto- 
gether unknown  in  some  situations  bordering  on  the  Rhine.' 
Calculous  affections  are  much  more  common  in  Manchester 
and  its  vicinity  than  in  any  other  part  of  England,  and  yet 
the  habits  of  the  residents  there  are  the  same  as  in  other  places. 
They  are  more  frequent  in  England  than  in  Scotland,  and  in 
Scotland  than  in  Ireland.  The  same  is  true  of  Russia.  In  the 
central  districts  of  the  Empire,  watered  by  the  upper  tributaries 
of  the  Volga,  calculous  disease  is  very  common,  while  it  is  ex- 
tremely rare  in  the  northern,  southern,  and  western  portions.  In 
the  Punjab,  northwestern,  and  central  provinces  of  India,  it  is 
very  prevalent,  554  cases  of  lithotomy  having  occurred  in  six 
months  of  1863.  In  Lower  Bengal,  on  the  other  hand,  stone  is 
not  very  frequent,  as  Professor  Fayrer^  states  that  only  about 
one  hundred  patients  were  cut  in  the  Medical  College  Hospital 
in  eleven  years.  It  is  very  frequent  in  France,  Germany,  Persia, 
and  Egypt,  its  production  in  the  last  country  depending,  in  some 
measure  at  least,  upon  inflammation  of  the  bladder  from  the 
presence  of  the  Bilharzia  Hematobia  in  its  mucous  coat.  In  Hun- 
gary the  disease  is  infrequent,  and  it  is  principally  met  with  in  the 
children  and  young  adults  of  the  peasant  and  artisan  classes. 

Certain  kinds  of  food  predispose  to  the  formation  of  calculous 
disease.  All  articles  whicli  have  a  tendency  to  create  acidity  and 
flatulence,  must  exert  a  deleterious  influence  upon  the  renal  secre- 
tion, changing  its  properties,  and  promoting  the  deposition  of 
earthy  matter.  How  far  the  constant  use  of  hot  bread,  biscuit, 
and  pastry,  which  are  consumed  in  such  enormous  quantities  in 
this  country,  especially  in  the  southwestern  States,  conduces  to 
lu'ing  about  calculous  disorders,  we  have  no  means  of  deciding. 
That  the  daily  employment  of  these  articles  has  a  tendency  to 
wear  out  the  strongest  stomach,  and  to  break  down  the  most 
vigorous  frame,  does  not  admit  of  doubt.  What  the  effects  of 
such  a  state  of  the  system  must  be  upon  the  urinary  secretion, 

'  Coulson,  op.  cit.,  p.  399. 

^  Clinical  and  Pathological  Observations  in  India,  1873,  pp.  385  and  391. 


170  STOXE    IX    THE    BLADDER. 

every  pathologist  knows.  A  weakened  digestion,  with  a  sour 
and  iiatulent  state  of  the  stomach,  constipation  of  the  bowels, 
and  an  irritable  condition  of  the  brain,  cannot  by  any  possibility 
produce  a  healthy  blood,  any  more  than  a  morbid  state  of  the 
blood  can  produce  a  healthy  urine.  It  has  been  supposed  that 
the  use  of  corn  bread  and  bacon  predisposes  to  the  development 
of  calculous  disorders.  That  such  may  be  the  case  is  possible  ; 
but  the  fact,  if  it  be  one,  remains  to  be  established.  The  negro 
of  the  southwest,  who  employs  hardly  any  otlier  kind  of  bread, 
and  whose  principal  meat  is  salt  bacon,  is  remarkably  exempt 
from  this  class  of  diseases ;  and  it  is  also  Avell  known,  at  least  to 
the  practitioners  of  that  region  of  country,  that  a  great  many  of 
the  calculous  patients  there  are  young  children  who  are  seldom 
sufficiently  fond  of  corn  bread  to  make  it  their  principal  food. 
In  Ohio,  wdiere  stone  is  perhaps  nearly  as  frequent  as  in  Ken- 
tucky, but  little  corn  bread  is  used,  while  in  the  latter  State  it 
forms,  in  many  families,  the  principal  table  diet.  In  Xorfolk, 
England,  where  calculous  complaints  are  exceedingly  frequent, 
corn  bread,  as  an  article  of  food,  is  unknown. 

"What  influence,  if  any,  the  inordinate  use  of  tea  and  coffee 
exerts  upon  the  production  of  this  disease,  is  not  ascertained. 
Unripe  beer  and  wine  seem  to  favor  the  development  of  uric  or 
oxalic  concretions  ;  while  good  Rhenish  wines  have  the  reputa- 
tion of  being  excellent  prophjdactics  against  this  class  of  att'ec- 
tions.  The  bitartrate  of  potassa,  which  most  of  these  wines 
contain  in  large  quantities,  is  supj^osed  by  Liebig  to  be  changed 
in  the  progress  of  digestion  into  the  carbonate  of  potassa,  which 
produces  an  alkaline  effect,  and  thus  counteracts  the  tendency 
to  the  deposition  of  lithic  acid.  Dr.  Dobson  remarked,  three- 
quarters  of  a  century  ago,  that  calculous  disorders  are  much  more 
frequent  in  the  cider  counties  than  in  other  parts  of  England. 
The  fact,  if  it  be  one,  may,  however,  be  a  mere  coincidence ;  for  it 
is  very  certain  that  nearly  all  sections  of  the  United  States  where 
cider  is  used  in  greatest  abundance,  are  eminently  free  from  this 
class  of  affections.  In  Xew  Jersey,  and  in  certain  parts  of 
Pennsylvania,  ]Srew  York,  and  Xew  England,  the  article  is 
drunk  in  large  quantities,  and  yet  it  is  very  uncommon  in  these 
localities  to  see  persons  suffer  from  stone  in  the  bladder. 

Many  respectable  writers  and  practitioners  are  of  the  opinion 


PHYSICAL    AND    CHEMICAL    PROPERTIES.  171 

that  the  procluctioii  of  calculous  diseases  is  promoted  by  the  use 
of  hard,  impure  water,  in  consequence  of  the  changes  which  it  is 
supposed  to  induce  in  the  renal  secretion.  The  opinion  is 
plausible,  and  may  be  true,  but  how  far,  or  to  what  extent  no 
one  has  attempted  to  decide.  If  it  be  true  that  in  Kentucky, 
Virginia,  Alabama,  Tennessee,  and  Ohio,  most  calculous  cases 
occur  in  limestone  regions,  it  is  equally  true  that  many  are 
found  in  the  freestone  districts  of  those  States. 

The  formation  of  stone  is  often  remarkably  favored  by  stric- 
ture of  the  urethra,  enlargement  of  the  prostate  gland,  organic 
disease  of  the  bladder,  and  cystitis  following  paralysis  of  the 
viscus  from  local  or  general  causes.  Whatever,  in  fact,  has  a 
tendency,  for  any  length  of  time,  to  obstruct  the  flow  of  urine, 
or  change  the  character  of  this  fluid,  whether  during  its  secre- 
tion or  after  its  arrival  in  the  bladder,  may  be  looked  upon  as 
a  predisposing  cause  of  this  disorder.  If  the  urine  happen 
under  these  circumstances  to  be  at  all  surcharged  with  earthy 
salts,  or  even  where  it  contains  merely  its  normal  proportions, 
more  or  less  of  these  substances  is  liable  to  be  retained  in  the 
bottom  of  the  viscus,  where  it  serves  afterwards,  in  many 
instances,  as  the  nucleus  of  a  calculous  concretion.  This  liabil- 
ity is  greatly  increased  Avhen  there  is  habitually,  along  with  the 
mechanical  ol)Struction,  an  inordinate  secretion  of  mucus.  It 
has  long  been  known  that  gout  and  rheumatism  are  eminently 
conducive  to  the  formation  of  uric  acid  calculi. 

Sect.  II.— PHYSICAL  AND  CHEMICAL  PROPERTIES.      . 

Most  calculi  have  a  central  nucleus,  upon  which  the  organic 
or  inorganic  elements  of  the  urine  accumulate  or  aggregate. 
This  nucleus  may  be  formed  by  any  substance,  whether  gene- 
rated in  the  urinary  organs,  or  introduced  from  without.  In 
the  great  majority  of  cases,  it  consists  of  uric  acid,  its  allies  or 
modifications,  as  is  seen  from  the  subjoined  table  of  the  analysis 
of  1613  calculi,  in  all  of  which,  save  189,  the  organic  elements 
of  the  urine  formed  the  starting  point  of  the  nuclei.  The  table 
at  the  same  time  aff'ords  an  opportunity  of  instituting  a  com- 
parison between  the  constitution  of  calculi  of  difterent  countries. 
Concretions  formed  upon  foreign  bodies  are  omitted. 


172 


STONE    IX    THE    BLADDER. 


Uric  acid 

Urate  of  ammonia. 

Other  urates  

Oxalate  of  lime  • . . 

Cystic  oxide 

Xanthic  oxide 

Phosphates  • 

Carbonate  of  lime 

Total 250 


, 

2 

81 

51 

23 

35 

55 

7 

73 

27  ; 

2 

19 

52  i 

4  ' 

250 

178 

6 

38 

14 
2 


17 
24 


68 


45 


6 

6 

T 

278 

95 

201 

1 128 
47 

15 

95 

16 

3 

11 

1 

1 

, . 

71 

22 

1 

649 

209 

127 

20 

10 

3 

43 


9 
2 

87 


Sometimes,  altliough  rarely,  the  nucleus  is  composed  of  ins})is- 
sated  mucus,  lymph,  epithelium,  coagulated  blood,  or  the  ova  of 
eutozoa.  Occasionally,  again,  the  concretion  is  formed  around  a 
foreign  body,  introduced  either  by  the  patient  himself  througli 
design  or  accident,  or  in  the  same  manner  by  a  second  party. 
A  person  shot  in  battle  has  been  known,  at  a  subsequent  period, 
to  suffer  from  stone  in  the  bladder,  in  consequence  of  the  ball 
having  lodged  in  that  organ,  and  thus  invited,  as  it  were,  a 
deposit  of  calcareous  matter.  A  surgeon  may  become  the  inno- 
cent cause  of  a  similar  occurrence.  In  treating  a  diseased  urethra, 
or  in  exploring  this  canal,  the  bladder,  or  the  prostate  gland, 
the  catheter,  bougie,  or  sound  which  he  uses  may  break  off,  and 
afterwards  lead  to  the  development  of  a  stone.  Many  such 
cases  are  upon  record.     A  great  variety  of  substances,  as  nails, 

tacks,  bullets,  needle-cases,  fruit- 
stones,  peas,  beans,  pebbles,  tents, 
hairs,  small  keys,  pipe-stems,  bits 
of  candle,  glass  tubes,  grass-stalks, 
pieces  of  straw,  barbs  of  wheat, 
cork,  human  teeth,  rings,  pins, 
and  needles,  have  been  accidentally 
lodged  in  the  bladder,  by  patients 
endeavoring  to  relieve  stricture,  to 
procure  evacuations  of  urine,  to  ex- 


Fia;.  33. 


Calculus  with  Nucleus  of  Cork. 


'  Sarahunpore  Dispensary,  India,  Dr.  Garden. 

^  MS.  Catalogue  of  Miittor  Museum,  College  of  Physicians  of  Philadelphia, 
Dr.  Bridges. 
*  :Museum  Med.  Dep't  Transylvania  University,  Kentucky.  Dr.  Peter. 
••  Warren  Museum,  Med.  Dep't,  Harvard  College. 
'  Museum  of  Royal  College  of  Surgeons  in  London. 
•>  Museum  of  Guy's  Hospital,  Dr.  Bird. 
■  Principally  Musee  Dupuytren,  Dr.  Bigelow. 
^  Collection  of  Professor  Reyer.  of  Cairo,  Egypt. 


PHYSICAL    AND    CHEMICAL    PROPERTIES.  178 

cite  onanism,  or  create  public  sympathy.  Examples  of  this  kind 
are,  for  obvious  reasons,  more  common  in  the  female  than  in 
the  male.  In  my  private  collection  are  specimens  in  which 
the  concretions  were  formed  around  the  tail-bones  of  a  squirel, 
an  elm  bougie,  a  piece  of  lead-pencil,  a  bullet,  and  a  needle. 
The  nucleus  is  sometimes  composed  of  hair,  bones,  or  teeth, 
derived  from  a  dermoid  tumor  whicli  has  evacuated  its  contents 
into  the  bladder.  In  the  annexed  drawing,  fig.  33,  taken  from 
a  preparation  in  the  cabinet  of  Dr.  Sabine,  of  Xew  York,  it 
consists  of  a  piece  of  cork. 

Finally,  the  nucleus  varies  much  in  size,  color,  form,  and  con- 
sistence. Although  generally  single,  it  is  sometimes  double, 
triple,  and  even  quadruple ;  its  situation  is  not  always  strictly 
central.  The  instances  in  which  the  concretion  is  hollow,  or  the 
nucleus  loose,  are  rare. 

Calculi  vary  much  in  their  number.  In  general,  there  is  only 
one;  now  and  then  there  are  two  or  three;  and  sometinies, 
although  rarely,  there  are  several  dozens,  or  even  several  hundred. 
The  largest  number  I  have  ever  found  was  fifty -four,  which  I 
removed  from  the  bladder  of  an  old  gentleman,  upwards  of 
seventy-six  years  of  age.  They  were  of  a  dull  whitish  color ; 
smooth,  irregular  in  their  shape,  and  from  the  size  of  the  kernel 
of  a  filbert  to  that  of  a  common  marble.  The  most  extraordi- 
nary example  upon  record  occurred  in  tiie  practice  of  the  late 
Dr.  Physick,  who  extracted  from  Judge  Marshall,  of  the  Supreme 
Court  of  the  United  States,  upwards  of  one  thousand  uric  acid 
calculi,  from  the  size  of  a  partridge  shot  to  that  of  a  bean.  They 
were  all  of  an  oval  shape,  and  were  marked' each  by  a  small  black 
spot.' 

The  mulberry  calculus  is  almost  always  solitary ;  and  the  same 
is  true,  but  not  to  the  same  extent,  of  the  uric  acid  calculus. 
The  phosphatic  calculus,  on  the  contrary,  is  not  infrequentlj^ 
multiple.  When  the  concretions  are  numerous,  they  are  always 
proportionately  small,  and  more  or  less  smooth  on  the  surface,  or 
provided  with  facets,  from  the  constant  friction  which  they  exert 
upon  each  other  in  the  bladder.  On  the  other  hand,  solitary 
stones  are  generally  rougli,  and  comparatively  large. 

The  volume  of  urinary  concretions  ranges  between  a  hemp-seed 
and  a  cocoa-nut.     In  the  great  majority  of  instances  it  does  not 

'  Gibson's  Institutes  of  Surgery,  ii.  p.  220.     Fifth  edition. 


174  STONE    IX    THE    BLADDER. 

exceed  that  of  an  almond,  a  pullet's  egg,  or  a  walnut,  the  latter 
of  which,  indeed,  it  seldom  reaches.  In  young  subjects,  and  in 
recent  cases  generally,  the  size  is  usually  inconsiderable.  I  have 
a  number  of  calculi,  extracted  from  children  from  three  to  five 
years  of  age,  which,  in  their  volume,  hardly  equal  a  common 
marble.  The  size  of  a  urinary  concretion,  however,  does  not 
necessarily  depend  upon  the  period  of  its  sojourn  in  the  bladder, 
or  the  aofe  of  the  patient.  Occasionally  it  increases  very  rapidly, 
so  as  to  attain  a  considerable  bulk  in  a  very  few  months;  and, 
on  the  other  hand,  it  may  remain  small  for  many  years.  In  1844, 
I  operated  upon  a  man  tAventy-six  years  old,  who  had  labored 
under  well-marked  calculous  sj'mptoms  from  his  earliest  infancy, 
and  yet  the  stone  was  hardly  as  big  as  a  hen's  egg. 

The  chemical  constitution  appears  to  exert  no  inconsiderable 
influence  upon  the  volume  of  urinary  concretions;  thus,  tlie 
ammoniaco-magnesian  and  the  fusible  calculi  are  capable  of 
attaining  a  very  large  size,  while  the  uric,  oxalic,  cystic,  xanthic, 
and  fibrinous,  are  almost  always  comparatively  small,  no  matter 
what  may  be  their  own  age  or  the  age  of  the  patient.  This  fact 
is  of  value  in  a  practical  point  of  view ;  because,  by  ascertain- 
ing the  calculous  diathesis  of  the  sufferer,  a  tolerably  correct 
idea  may  be  formed  as  to  the  volume  of  the  stone  under  which 
he  is  laboring.  It  is  interesting  to  note,  however,  that  in  a  case 
recorded  by  Mr.  "Williams,  a  uric  acid  calculus,  which  weighed 
twenty -five  ounces,  and  measured  ten  and  a  half  inches  in  its 
short  circumference,  and  twelve  and  a  half  in  its  long  circum- 
ference, was  removed,  after  death,  from  the  bladder  of  a  gentle- 
man, eighty-one  years  of  age. 

It  has  been  already  seen  that,  when  urinary  calculi  coexist  in 
great  numbers,  they  are  always  proportionately  small.  In  the 
most  remarkable  case  of  this  kind  upon  record — that  of  Judge 
Marehall,  previously  referred  to — the  size  of  none  of  the  concre- 
tions, which  amounted  to  upwards  of  one  thousand,  exceeded 
that  of  a  bean,  while  many  of  them  were  not  larger  than  a 
partridge  shot.  It  is  worthy  of  remark  also,  that,  under  these 
circumstances,  the  individual  calculi  are  generally  of  unequal 
dimensions. 

The  consideration  of  the  weight  of  urinary  concretions  is 
necessarily  connected  with  that  of  their  volume.  In  general, 
this  does  not  exceed  a  few  drachms  or  ounces.  Out  of  every  one 
hundred  calculi,  as  thev  occur  in  the  cabinets  of  different  institu- 


PHYSICAL    AND    CHEMICAL    PEOPERTIES.  175 

tions,  or  of  private  individuals,  few  will  be  found  to  weigh  more 
than  live  or  six  drachms.  One  of  tlie  snjallest  eA-er  removed  by 
lithotomy,  weighed  onl}^  ten  grains;  the  operator  was  Mr.  Mar- 
tineau,  of  England,  and  the  patient  a  hoy,  thirteen  years  old. 
In  one  of  mj'  own  cases,  that  of  a  hoy,  six  years  of  age,  the 
weight  of  the  calculus  was  only  five  grains.  Many  examples, 
however,  are  recorded  of  four,  six,  eight,  ten,  twelve,  fifteen, 
and  even  sixteen  ounces.  Instances  of  eighteen,  nineteen,  and 
twenty  ounces,  are  related  by  Borellus,  Lusitanus,  Cheselden, 
Pauw,  Foschini,  Wrisberg,  and  Sandifort,  Fabricius  Hildanus 
describes  a  calculus  which  weighed  twenty-two  ounces,  and  was 
four  inches  and  a  half  in  length,  by  three  and  a  half  in  breadth. 
Examples  of  from  twenty-four  to  thirty  ounces  are  recorded  by 
Deschamps,  Pauw,  Paget,  Tolet,  Williams,  King,  and  other 
authors.  In  the  case  mentioned  by  the  latter,^  the  patient,  who 
was  forty-six  years  of  age,  had  suftcred  from  his  infancy,  and 
the  stone  was  seven  inches  and  a  half  long,  bj^  fifteen  inches  in 
circumference.  •  Several  instances  exist  in  which  the  concretion 
weighed  thirty-five,  forty,  forty-five,  and  even  fifty  ounces.  Mr. 
Henry  Earle,^  of  London,  has  published  the  particulars  of  a 
calculus  which  weighed  forty-four  ounces,  and  was  sixteen 
inches  in  circumference.  It  was  impossible  to  break  it,  and  the 
operator  was  compelled  to  leave  his  task  unfinished.  Deschamps 
gives  a  case  of  fifty-one  ounces;  Verduc,  one  of  three  pounds 
three  ounces;  and  Kesselring^  one  of  upwards  of  six  pounds. 

jSTot  a  little  diversity  obtains  iii  respect  to  the  consistence  of 
vesical  concretions.  As  a  general  rule,  it  may  be  said  to  vary 
from  that  of  semiconcrete  mortar,  chalk,  or  wax,  to  that  of  stone 
or  marble.  The  hardest  calculi  are  the  oxalic  and  uric,  which 
generally  emit  a  clear  sound  when  .struck  with  steel,  and  cannot 
be  fractured  without  a  considerable  degree  of  force.  Calculi,  on 
the  other  hand,  composed  of  animoniaco-magnesian  phosphate 
and  phosphate  of  lime,  are  friable,  and  easily  reduced  to  powder. 
In  extracting  such  concretions  from  the  bladder,  they  not  infre- 
quently break  under  the  pressure  of  the  forceps.  The  cystic  and 
fibrinous  calculi  are  quite  soft,  the  latter  scarcely  equalling  that 
of  \'ellow  wax.     It  often  happens  that  one  part  of  a  stone  is  hard 

'  London  Medical  and  Physical  Journal  for  1838. 

2  London  Medico-Chir.  Trans.,  vol.  xi.  p.  82. 

3  Commer.  Liter.  Norimb.  1739,  liebd.  9. 


176  STONE    IX    THE    BLADDER. 

and  compact,  while  another  is  soft,  friable,  or  even  pulverulent. 
This  diversity  of  consistence  is  strikingly  exhibited  in  what  are 
denominated  the  alternating  calculi,  and  seems  to  depend,  in 
great  measure,  if  not  entire!}-,  upon  the  component  elements  of 
the  diiferent  layers  of  which  such  concretions  consist.  It  is  not 
improbable  that  the  age  of  a  stone  may  exert  some  influence  upon 
its  consistence,  though  it  is  impossible  to  estimate  the  amount 
or  degree  of  it. 

Stones  are  occasionally  composed   of  a   mixture  of  sabulous 
matter  and  hair,  more  or  less  intimately  matted  together.     Their  | 
consistence   resembles  that  of  old  lath-plaster;  they  are  easil}'  ' 
crushed  or  pulverized,  and  they  are  of  a  whitish,  grayish,  or 
pale-drab  color.     Their  formation  is  of  rare  occurrence,  and  they  I 
appear  to  consist  princijially  of  phos])hate  of  lime  and  magnesia, 
aggregated  on  hair  derived  from  dermoid  cj'sts,  or  introduced 
from  without. 

The  color  of  these  bodies  is  not  less  variable  than  their  othei 
physical  properties.  •  The  most  common  shades  are  white,  grayi 
ish,  drab,  fawn,  reddish,  rose,  and  brown.  Concretions  of 
bluish,  greenish,  black,  or  slate  color  are  rare.  In  the  alternat 
ing  calculi,  a  combination  of  tints  is  generally  observable,  anc 
even  one  part  of  the  surface  of  a  stone  may  differ  essentially,  ii 
this  respect,  from  another.  The  cystic  and  fibrinous  calculi  ar< 
of  a  yellow  color,  not  unlike  that  of  yellow  wax;  the  phosphatic 
are  whitish  or  grayish;  the  oxalic,  dark  or  blackish;  the  uricj 
rose,  reddish,  or  brown. 

ISIost  calculi,  at  the  moment  of  their  extraction  from  th( 
bladder,  and  for  a  short  time  afterwards,  emit  a  strong  urinousl 
odor,  which  they  gradually-  lose  by  exposure  to  the  atmosphere.1 
It  may  also  be  completely  destroyed  by  ablution  in  warm  water,| 
and  rapid  desiccation  before  tlie  fire.  More  or  less,  however,  oi 
the  animal  matter  is  usually  retained,  so  that  maceration  at  any! 
future  time,  if  not  too  remote,  is  apt  to  be  followed  by  a  slight! 
reproduction  of  the  original  odor.  When  sawed,  rasped,  or 
rubbed,  urinary  concretions  give  out  a  smell  similar  to  that  oi 
bone,  horn,  or  ivory.  Fourcroj-  considered  the  spermaceti  odor! 
furnished  by  mulberry  calculi,  thus  treated,  as  characteristic  ot 
the  species;  this,  however,  is  a  mistake. 

Vesical  calculi   are   capable  of  assuming  a  great  variety  oi 
forms.     The  circumstances  which  are  chiefly  concerned  in  pr( 
ducing  this  result  are  the  action  of  the  bladder,  the  frictioi 


PHYSICAL    AND    CHEMICAL    PROPERTIES.  177 

wliich  the  concretions,  wlien  mnltiple,  exert  upon  one  another, 
and  the  nature  of  the  nucleus.  Thej  are  commonlj  of  an  oval 
outline,  but  occasionally  they  are  round,  spherical,  or  even 
cylindrical.  Other  varieties  of  form  are  sometimes  seen,  as  the 
conical,  pj^riform,  cul)ic,  triano'ular,  p)yramidal,  gourd-like,  }K:)ly- 
gonal,  and  the  tetrahedrah  Sometimes  the  concretion  is  thin 
and  liat,  like  a  coin,  lenticular,  semilunar,  or  in  the  shape  of  a 
mushiTKim,  a  kidney,  a  mulberry,  a  bean,  or  a  heart.  Again,  it 
may  be  large  and  bulbous  at  the  extremities,  and  narrow  a^t  the 
middle,  like  a  dumb-bell.  Dr.  ^Alussey,  Professor  of  Surgery  in 
the  Miami  Medical  College,  Cincinnati,  showed  me,  some  years 
ago,  a  most  singuhirly  shaped  calculus,  I'epresented  in  tig.  34, 
which  had  been  removed  after  death  from  the 
bladder  of  a  man  who  had  long  labored  under 
disease  of  that  organ.  It  is  of  a  light-brownish 
color,  and  consists  of  a  central  portion  and  a 
niimlK'r  of  distinct  processes,  each  of  which  has  a 
small  cavity  containing  animal  matter.  The  pro- 
cesses are  remarkably  rough,  and  several  of  them  ThomyCaicuii.s. 
are  nearly  iialf  an  inch  in  length.  Its  composition  is  supposed 
to  be  oxalate  of  lime. 

Large  concretions  occasionally  assume  the  form  of  the  bladder, 
and  even  send  prolongations,  points,  or  processes  into  the  urethra, 
the  ducts  of  the  prostate  gland,  and  the  ureters.  A  remarkable 
specimen  of  this  nature  was  presented  to  the  Pathological  Society 
«>f  London,  by  Mr.  Furneaux  Jordan,'  in  1867.  A  triple  phos- 
Ithate  calculus  formed  a  mould  of  the  ajiex,  body,  base,  and 
trigone  of  the  bladder,  the  openings  of  the  urethra  and  ureters, 
and  was  the  seat  of  a  circular  depression  caused  by  a  hypertro- 
phoid  ba\id  of  muscular  fibres.  In  tlie  case  from  which  the 
annexed  skctcli,  tig.  85,  was  taken,  the  calculus  was  lodged  partly 
in  the  urethra  and  partly  in  the  bladder,  in  the  former  of  which 
it  reached  as  far  forward  as  the  bull) ;  it  was  cut  out  of  a  lad  in 
St.  George's  Hospital,  London,  and  was  composed  almost  entirely 
of  the  mixed  phosphates.^  "In  its  appearance,  it  is  not  unlike 
tlie  liead  and  part  of  the  neck  of  a  turkey-poult,  when  prepared 
for  the  spit." 

Occasionally,  again,  the  concretion  consists  of  several  i)iece.s 

'  Trans.  Path.  Soc.  London,  voL  xviii.  p.  179. 
^  BromfieUrs  Chir.  Observalions  and  Cases,  voL  ii.  plate  10. 
]2 


178 


STONE    IN    THE    BLADDER. 


winch  are,  as  it  were,  articulated  with  each  other,  as  in  the 
remarkahlc  specimen  represented  in  fig.  36,  copied  from  Palluci.' 
In  this  case,  one  of  the  pieces  projected  into  the  scrotum  and 


Fis.  35. 


F\s.  36. 


Fig.  3').     a.  The  urethral,  and  6,  the  vesical  portion. 

Fig.  36.     n.  Urethral  portion  ;  b,  the  scrotal,  and  c,  the  vesical. 

another  into  the  urethra,  while  the  third,  or  smallest  one,  lay  in 
the  cavity  of  the  bladder.  The  calculus,  which  weighed  four 
ounces  and  a  half,  and  was  nearly  cylindrical  in  its  form,  was 
three  inches  and  three-quarters  in  length  by  an  inch  and  a  half 
in  thickness.  The  engraving  is  about  one-half  the  natural  size. 
Sometimes  several  concretions  are  matted  together,  so  as  to 
form  what,  in  geological  language,  is  termed  a  pudding-stone. 
I  have  never  seen  an  instance  of  this  kind ;  but  a 
beautiful  specimen,  represented  in  fig.  37,  is  described 
by  Professor  Erichsen,  in  his  treatise  on  surgery.  It 
was  removed  by  him  from  a  child,  and  consists  of 
eleven  distinct  lithic  acid  calculi  soldered  together 
l)y  eartliy  matter. 

Morgagni  speaks  of  a  stone,  voided  by  a  female, 
which  was  perforated  at  the  centre.     Sometimes  a 
calculus  is  very  porous,  or  marked  by  numerous  apertures,  as  if 


FiK.  37. 


Pndding-Stone 
Calculus. 


'  Litliotomie  Xouvellement  Perfectiounee,  p.  53.     Vienna,  1757. 


PHYSICAL    AND    CHEMICAL    PROPERTIES.  179 

it  had  been  exposed  for  a  long  time  to  the  action  of  the  urine. 
In  a  word,  there  is  literally  no  end  to  the  grotesque  appearances 
ot  these  bodies. 

Finally,  the  shape  of  a  calculus,  as  already  stated,  is  some- 
times materially  influenced  by  that  of  its  nucleus.  If  this  be 
long,  as  when  it  consists  of  a  piece  of  catheter,  bougie,  straw,  or 
liower-stalk,  the  concretion  will  also  be  apt  to  be  long  and  slen- 
der, the  reverse  being  the  case  when  the  neucleus  is  rounded,  or 
ovoidal.  The  fact  is  interesting  in  regard  to  the  manner  in 
which  the  foreign  body  should  be  seized  with  the  forceps,  with 
a  view  to  its  removal  from  tlie  bladder,  whether  this  be  at- 
tempted by  incision,  or  the  natural  channel. 

The  surface  of  these  concretions  may  be  smooth  or  rough. 
The  former  is  generally  the  case  when  several  exist  together, 
from  the  friction  which  they  exert  upon  each  other ;  when  there 
is  only  one,  hoAvever,  it  is  almost  always  rough.  From  the 
cause  just  mentioned,  multiple  calculi  may  not  only  be  smooth, 
but  even  highly  polished,  and  rendered  angular,  polj^gonal, 
rhoraboidal,  or  tetrahedral.  The  oxalic  concretion  derives  its 
common  name  from  the  roughness  of  its  surface,  which  resembles 
that  of  the  fruit  of  the  mulberry.  The  uric  acid  calculus  is 
usually  finely  tuberculated.  In  some  of  these  foreign  bodies, 
the  surface  is  scabrous,  mammillated,  knotty,  convoluted,  or 
covered  with  spines,  prongs,  or  stalactites. 

That  urinary  concretions  vary  very  much  in  tlieir  chemi- 
cal constitution  in  different  localities,  is  evinced  by  the  table 
given  at  ])agc  172.  The  oxalate  of  lime  calculi  in  the  Grant 
Medical  College  Museum  at  Bombay  amount  to  38.65  per  cent. ; 
in  Guy's  Hospital,  London,  to  22.59  per  cent. ;  in  the  RoyaL 
College  of  Surgeons  to  14.72  per  cent. ;  and  in  the  Xorwich  HoPi 
pital  to  13.27  per  cent.  Uric  acid  calculi  occur  in  smaller  pro- 
portions in  India  than  in  England  ;  and  as  to  phosphatic  calculi 
they  reach  only  3.86  per  cent,  in  the  former,  while  they  amount 
to  10  per  cent,  in  the  latter.'  In  Egypt,  pure  phosphatic  con- 
cretions are  almost  unknown,  and  oxalate  of  lime  calculi  amount 
to  only  12.5  per  cent.  Dr.  A.  H.  Ilassall,  of  London,  states 
that  of  1000  calculi,  372  consisted  of  uric  acid,  either  pure  or 
mixed  with  small  quantities  of  the  urates  or  oxalate  or  phos- 

'  Carter's  account  of  Calculi  in  India,  as  quoted  in  Beale's  Arcnives  ot'^Medi- 
cine,  No.  6,  p.  143,  1800. 


180 


STONE    IX    THE    BLADDER. 


phate  of  lime;  2o3,  cliictly  fusible  concretions,  of  the  earthy 
|)hosphates;  233  of  varying  lax'ers  of  uric  acid,  oxalate  of  lime, 
and  earthy  phosphates  ;  and  142  of  oxalate  of  lime. 

The  subjoined  account,  wliich  is  transferred,  with  little  altera- 
tion, from  ni}'  work  on  Pathological  Anatomy,  includes  tbe  most 
important  species  of  urinary  concretions  that  have  hitherto  been 
described. 

The  uric,  or  litiiic,  acid  calculus,  the  most  common  species  of 
all,  forming  as  it  does  about  one-fourth  or  one-firth  of  all  calculi, 
Avas  iirst  noticed  by  Scheele,  in  1776.  In  its  color  it  is  brownish, 
inclining  to  that  of  mahogany,  of  a  flattened  oval  shape,  occa- 
sionally tincly  tul)erculated  on  tbe  surface,  but  most  generally 
smooth,  altliough  not  polished,  unless  there  are  several  concre- 
tions at  the  same  time,  and  from  the  size  of  a  currant  to  that 
of  a  hen's  egg.  When  divided,  it  will  be  found  to  consist  of 
several  layers  arranged  concentrically  around  a  common  nucleus, 
the  lamini^  being  frequently  distinguishable  from  each  other  by 
a  slight  ditfercnce  in  color,  and  sometimes  by  the  interposition 


Fiff.  38. 


Fiff.  39. 


Uric  Acid  Calculi. 


of  other  ingredients.  AVater  has  but  little  action  upon  it;  it  is 
perfectly  dissolved  by  carbonate  or  hydrate  of  potassa  without 
the  evolution  of  ammonia;  and  dissappears  with  effervescence  in 
hot  nitric  acid,  the  solution  affording,  on  evaporation  to  drjmess, 


PHYSICAL    AXD    CHEMICAL    PROPERTIES. 


181 


a  liright  carmine-colored  residue,  which  becomes  ]:)urple,  on  the 
a(Ulition  of  ammonia.  As  the  same  reaction  is  atforded  by  the 
urates,  the  discrimination  can  only  l)e  made  by  the  microscope. 
Before  the  blowpipe,  it  becomes  black,  emits  a  peculiar  animal 
odor,  and  is  gradually  consumed,  leaving  a  minute  quantity  of 
white  alkaline  ashes.  Fig.  38  shows  the  oval  shape  and  Unely 
tuberculated  surface  of  the  calculus;  tig.  39  the  internal  concen- 
tric layers. 

A  variety  of  the  preceding,  is  the  urate  of  ammonia  calculus, 
which  is  principally  observed  in  children,  and  is  so  extremely 
rare  that  several  distinguished  chemists  have  been  induced  to 
deny  its  existence.  Of  1043  calculi,  however,  in  the  museums  of 
the  Royal  College  of  Surgeons,  Edinburgh,  and  Guy's  Hospital, 
21  are  composed  of  tliis  substance.  It  is  generally  of  small  size, 
with  a  smooth  surface,  of  a  slate  or  a  clay  color,  and  composed 
of  concentric  rings,  which  present  a  very  tine  earthy  appearance 
when  fractured.  Much  more  soluble  in  water  than  the  uric  acid 
calculus,  it  gives  out  a  strong  ammoniacal  smell  when  heated 
with  caustic  potassa,  and  deflagrates  remarkably  under  the  blow- 
pipe. This  variety  of  calculous  concretion  was  tirst  described  by 
Fourcroy  and  Yauquelin  in  1798. 

The  oxalate  of  lime  calculus,  which  forms  about  the  one-soven- 
teentli  of  all  calculi,  is  generally  of  a  dark  brown  color,  rough. 


Fi^^  40. 


Fi.iT.  41. 


Oxalme  of  Lime  Calculi. 


Spinous,  or  tuberculated  on  the  surface,  ver^-  hard,  compact,  and 
imperfectly  laminated,  seldom  larger  than  a  walnut,  spherical, 
and  always  single.  Under  the  blo\vpi]ie,  it  expands  and  efflo- 
resces into  a  white  powder;  it  dissolves  slowly  in  hydrochloric 


182 


STOXE    IX    THE    BLADDER. 


Ficr.  42. 


and  nitric  acid,  provided  it  be  previously  well  broken  up.  lu 
the  alkalies,  it  is  perfectly  insoluble.  This  species  of  urinary 
concretion,  called  by  many  the  mulberry  calculus,  from  its 
resemblance  to  the  fruit  of  that  name,  was  first  correctly  analyzed, 
in  1797,  by  Dr.  AVollaston,  who  proved  it  to  consist  essentially 
of  oxalate  of  lime.  Figs.  40  and  41  show  the  external  and 
internal  appearances  of  this  concretion. 

A  variety  of  this  species  of  calculus,  represented  in  fig.  42, 
h{i«  been  described  by  the  term  hemp-seed,  from  some  resem- 
Idance  which  it  heai^s  in  color  and  lustre  to  that  sub- 
stance. It  is  always  of  small  size,  remarkably  smootb, 
and  generally  exists  in  considerable  numbers,  being 
rarel}',  if  ever,  found  alone. 

A  very  rare  species  of  urinary  concretion  is  the  cystic 
oxide,  so  called  by  AVollaston,  in  1810,  from  an  erroneous 
supposition  that  it  was  peculiar  to  the  bladder.  It  consists  of  a 
confused  crystallized  mass,  of  a  whitish-yellow  wax-like  lustre, 
with  a  smooth  or  smoothly  tubercular  surface.  The  structure  is 
compact,  and  the  fracture  exhibits  a  peculiar  glistening  lustre, 
like  that  of  a  bod\'  having  a  high  refractive  density.  It  exhales 
a  strong  characteristic  odor  under  the  blowpipe,  and  is  very  abun- 
dantly dissolved  in  acids  and  alkalies,  with  both  of  which  it 
crystallizes.  This  species  is  commonly  of  an  irregular,  spherical 
shape,  and  seldom  attains  a  large  volume.  The  external  and  in- 
ternal features  of  the  cystic  calculus  are  shown  in  figs.  43  and  44. 


FiL^  ^^. 


FiiT.  44. 


Cystic  Oxide  Calculi. 


As  an  evidence  of  the  rarity  of  this  variety  of  concretion,  it 
may  be  stated  that,  in  the  collection  of  calculi  in  the  Ilunterian 
Museum,  embracing  six  hundred  and  forty-nine  specimens,  there 
are  but  three  of  the  cystic  oxide.  The  other  London  cabinets 
have  hardly  any  examples;  aiKl  M.   Civiale,  in  his  immense 


PHYSICAL    AND    CHEMICAL    PROPERTIES.  183 

practice,  had,  up  to  1851,  met  with  it  only  eight  times.  The 
Lexino;ton  collection,  according  to  Dr.  Peter,  contains  but  two 
specimens.  Dr.  J.  M.  Warren,  of  Boston,  a  few  years  ago  suc- 
cessfully removed  a  concretion  of  this  kind  by  crushing.'  I  have 
not  found  the  cystic  oxide  in  any  of  my  operations.  Mr.  Poland^ 
states  that  there  is  a  remarkable  hereditary  disposition  to  its 
formation,  since  out  of  22  collected  cases,  10  occurred  in  four 
families,  and  in  3  cases  in  brothers. 

The  xanthic,  or  uric,  oxide  calculus  was  first  pointed  out  by 
Dr.  Marcet,  whose  account  of  it  is  the  best  that  is  extant.  It  is 
exeremely  rare,  having  been  met  with  only  three  times  in  man. 
Its  texture  is  compact,  hard,  and  laminated ;  its  color  is  of  a 
cinnamon  brown,  its  surface  smooth,  and  its  volume  small.  It 
dissolves  very  readily  in  acids  and  alkalies,  and  is  gradually 
consumed  before  the  blowpipe,  leaving  a  minute  quantity  of 
white  ashes. 

The  phosphate  of  lime  calculus,  shown  in  fig.  45,  and  described 
bj'  Wollaston   in   1797,  is  of  a  pale  brownish 
color,  and  of  a  loosely  laminated  structure,  with  ^^' 

a  smooth,  polished  surface,  like  porcelain.     The     ^^^^^^^ 
shape  is  mostly  oval,  and  the  size,  although  gene-     ^,    V7-  o,    , 

i  J  '  '  .->      n  Phospliatic  Calculus. 

rally  small,  is  sometimes  very  considerable.  It 
whitens  when  exposed  to  the  blowpipe,  but  does  not  fuse ;  and 
readily  dissolves  in  hj'drochloric  acid,  without  effervescence. 
This  calculus  is  extremely  rare,  as  forming  entire  concretions, 
but  frequently  constitutes  alternate  layers  with  other  matters. 
It  is  sometimes  called  the  bone-earth  calculus,  and  occasionally 
contains  small  quantities  of  carbonate  of  lime. 

The  next  species  is  the  triple  or  ammoniaeo-magnesian  phos- 
phate, so  called  from  its  being  composed  of 
tlie  phosphate  of  ammonia  and  magnesia,  I*"'2:-  4'>- 

and  represented  in  fig.  46.  This  mixed  cal- 
culus is  of  a  white  color,  friable,  crystallized 
on  the  surface,  and  looks  a  good  deal  like  a 
mass  of  chalk  ;  its  texture  being  never  lami- 
nated, it  easily  dissolves  in  dilute  acids,  but 
is  insoluble  in  caustic  potassa;  before  the 

11  .  -ill  •  1         1  Aniinoniaco-inaguesiaa 

DlOAvpq^e,  it  exhales  an  ammoniacai  odor,  caicuius. 

'  Dr.  G.  Blackmail,  New  York  Jonrn.  'SU-d.  and  Surgery,  Jan.  1852,  p.  109. 
2  Holmes's  System  of  Surgery,  vol.  iv.  p.  1035. 


184 


STOXE    IN    THE    BLADDER. 


and  at  length  melts  into  a  vitreous  substance.  This  species  of 
concretion,  also  discovered  by  Wollaston  in  1797,  sometimes 
attains  an  immense  size.  In  a  case  mentioned  by  Dr.  Thompson, 
the  circumference  Avas  fourteen  inches,  and  the  weight  nearly 
two  pounds. 

The  fusible  calculus,  or  mixed  phosphate,  the  nature  of  whiclj 
was  iii^t  determined  by  Wollaston,  consists  of  a  eomlrlnation  of 
the  last  two.  It  is  of  a  white  or  gray  color,  very  light  and  of 
low  specific  gravity,  extremely  brittle,  leaves  a  soft  dust  on 
the  lingers,  and  is  easily  separated  into  laj-ers ;  when  broken, 
it  presents  a  ragged,  uneven  surface.  It  is  insoluble  in  caustic 
potassa,  but  o-ives  oft'  ammonia ;  and,  under  the  blowpipe,  it  is 
i:eadily  converted  into  a  transparent,  pearly -looking  glass.  This 
concretion  forms  about  one-twelfth  of  all  calculi,  and  sometimes 
attains  a  very  large  size.  It  is  frequently  met  with  as  an  in- 
crustation of  foreign  bodies.  Figs.  47  and  48  exhibit  the  outer 
appearance  and  internal  structure  of  this  concretion. 


Fi-r.  47. 


Fi--.  48. 


Fusible  Calculi, 


The  carbonate  of  liuie  calculus,  wliich  was  first  described  by 
Brugnatelli  in  1819,  is  very  uncommon.  It  is  usually  multiple, 
of  a  white  or  light  brown  color,  and  of  small  size.  When  of  a 
light  hue  it  is  friable ;  but  when  of  a  dark  color  it  is  very  dense 


PHYSICAL    AXD    CHEMICAL    PROPERTIES.  185 

and  compact.  It  effervesces  freely  when  acted  upon  by  acids 
previous  to  incineration. 

The  fibrinous  calcuhis,  like  the  preceding  species,  is  also  ex- 
tremely rare,  and  appears  to  be  composed  [irincipally  of  tiie 
fibrin  of  the  blood,  a  property  to  which  it  owes  its  name,  and  by 
which  it  is  characterized.  Sir  Benjamin  Brodie'  has  described 
a  concretion  of  this  kind,  which  was  about  the  size  of  a  horse- 
bean,  of  an  oval  shape,  and  of  a  yellow  transparent  appearance, 
not  unlike  amber,  but  less  hard.  When  dried,  it  shrunk  to  a 
small  size,  and  became  considerably  shrivelled. 

There  is  a  sing-ular  concretion  described  by  Heller,  under  the 
name  of  urostealith.  It  is  exceedingly  rare,  and  I  do  not  know 
that  any  one  else,  except  Dr.  Moore,  of  Dulilin,  has  noticed  it. 
The  specimen  analyzed  by  the  German  cliemist  was  passed  by  a 
man  of  tolerablj^  good  constitution,  twentj'-four  years  of  age, 
whose  chief  complaint  was  pain  in  the  region  of  the  right  kid- 
ney, with  difficult}'  in  micturition.  The  concretions  were  of  a 
rounded  form,  soft,  elastic,  and  from  the  volume  of  a  hemp-seed 
to  that  of  a  hazelnut,  most  of  them  being  as  large  as  a  pea. 
They  become  brittle  on  being  dried,  when  they  present  the  ap- 
pearance of  wax,  of  a  greenish-yellow  hue  when  viewed  by  trans- 
mitted light.  When  heated,  they  melt,  and  emit  a  peculiar, 
pungent  odor,  similiar  to  that  of  benzoin.  Urostealith  is  readily 
dissolved  by  ether  and  by  solutions  of  caustic  potassa,  Init  it  is 
insoluble  in  boiling  water,  and  nearly  so  in  alcohol.  It  seems 
to  be  composed  of  a  peculiar  kind  of  fatty  matter. 

Finally,  all  calculi,  whatever  may  be  their  composition  and 
consistence,  contain  a  certain  amount  of  animal  matter,  which, 
being  diffused  through  their  interior,  serves,  like  so  nuu-li 
cement,  to  bind  together  their  various  constituents.  It  presents 
itself  in  different  forms,  the  most  common  of  which  are  allui- 
men,  mucus,  and  epithelium,  but  occasionally  we  meet  Avith 
blood,  pus,  and  other  secretions,  although  rarely  in  any  consider- 
able quantity.  The  rapidity  with  which  certain  concretions  are 
formed  is  often  greatly  influenced  by  the  amount  of  animal 
matter  present  in  the  urine,  or  upon  the  surface  of  the  calculus. 
Professor  Scharling,-  of  Copenhagen,  lays  much  stress  u[ion  this 

•  Lectures  on  the  Urinaiy  Organs,  p.  014.  sfoond  edition.     Lomlnn.  is;.".. 
^  On  the  Chemical  Discrimination  ot  Vesical  Calculi,  tiaiislalcd  by  Dr.  S    E. 
lloskins,  p.  11-1.     London,  1812. 


186  STONE    IN    THE    BLADDER. 

subject,  in  relation  to  which  he  makes  the  following  pertinent 
remarks:  "The  degree  of  rapidit}^"  says  he,  "with  which  pre- 
cipitation takes  place  depends  on  various  causes.  Among  these 
may  be  enumerated  the  envelopment  of  the  nucleus  in  albumen, 
blood,  mucus,  pus,  or  any  other  organic  matter  that  chances  to 
be  present  in  sufficient  quantit3\  These  form  a  villous  coating 
around  the  solid  material,  and  tlieirflocculi  arrest,  entangle,  and 
ultimately  determine  the  cr\'stallization  of  the  more  insoluble 
ingredients  of  the  urine.  This  explanation  will  go  far  to  account 
for  the  animal  matter  contained  in  all  calculi ;  the  presence  of 
which  adds  so  greatly  to  the  difficulty  of  distinguishing  their 
constituents.  It  accounts  also  for  the  spongy  interstices  inter- 
posed between  layers  of  a  denser  structure;  and  explains  why 
certain  calculi  are  full  of  small  foramina. 

"  These  organic  substances,  as  they  exist  so  constantly  in 
calculi,  may  be  regarded  as  the  cement  wliich  binds  calculous 
constituents  together;  and  not  only  favors  their  increase,  but  in 
very  many  instances  first  lays  the  foundation  for  precipitation. 
If  we  attentively  examine  any  of  the  fissured  and  perforated 
calculi  so  often  met  with,  or  those  in  which  a  central  mass  of 
crystals  replaces  the  usual  nucleus,  we  shall  have  evidence  of  the 
manner  in  which  a  clot  of  blood,  or  a  flake  of  mucus  or  albumen, 
detains  the  solidifiable  ingredients,  the  hydrate,  as  it  were,  and 
forms  the  elements  of  a  nucleus,  which  consolidates,  and  in  its 
turn  constitutes  the  centre  for  future  deposition." 

Dr.  E.  B.  Haskins,'  of  Clarksville,  Tennessee,  who,  some  years 
ago,  investigated  this  subject,  has  ascertained  that  if  a  small 
quantity  of  calculous  matter,  imperfectly  pulverized,  and  partially 
dissolved,  be  placed  under  a  microscope,  the  particles  thus  treated 
will  be  found  to  be  enveloped  by  a  pellicle  of  transparent  animal 
matter,  which,  when  completely  divested  of  salts,  bears  so  great 
a  resemblance  to  epithelial  scales  as  to  be  easily  mistaken  for 
them.  His  observations,  which  were  made  with  much  care,  con- 
firm those  of  Scljarling  and  other  chemists  in  relation  to  the 
intimate  penetration  of  all  calculi  ^^\  this  substance,  which  thus 
forms,  as  it  were,  a  kind  of  network  for  the  reception  and 
accommodation  of  the  saline  deposit.  In  addition  to  this  matter. 
Dr.  Haskins  often  detected,  in  the  concretions  wliich  he  examined, 

'  MS.  letter  to  the  author,  July  29,  18.54. 


SITUATION".  187 

epithelial  scales  from  the  bladder  and  kidney,  fibrinous  casts 
from  the  uriniferoiis  tubes,  and  a  peculiar  fibriniform  matter 
without  any  definite  structure.  The  central  portion  of  the  con- 
cretions always  contained  a  large  proportion  of  these  substances, 
which  were  sometimes  easily  broken  down,  but,  in  general,  they 
were  tough  and  adherent.  He  thinks,  moreover,  that  no  calculus 
can  form  without  the  aid  of  matter  foreign  to  the  urine  in  a 
chemical  sense,  and  that  this  matter  is,  as  has  been  alread}-  seen, 
uniformly  of  an  animal  character. 

Sect.  III.— SITUATION. 

Calculi  generally  lie  loose  within  the  cavity  of  the  bladder, 
and  are,  consequently,  liable  to  shift  their  position,  not  only  with 
that  of  the  viscus  in  which  they  are  contained,  but  also  with  that 
of  the  body.  A  knowledge  of  this  variation,  in  the  position  of 
these  foreign  substances,  is  of  no  little  importance  in  regard  to 
the  operation  of  sounding.  Their  most  common  situation  is, 
undouljtedl}',  the  bas-fond  of  the  bladder,  from  the  foct  that  thi.s 
is  the  most  dependent  portion  of  the  reservoir.  In  old  subjects, 
affected  with  enlargement  of  the  prostate,  the  concretion  gene- 
rally lies  just  behind  tliis  body,  in  a  sort  of  pouch,  or  cul-de-sac. 
Wlien  this  is  tlie  case,  and  the  calculus  is  of  large  size,  it  may 
often  be  easily  felt  by  the  finger  in  the  rectum.  When  the 
bladder  is  perfectly  sound,  the  concretion,  especially  when  the 
patient  is  in  the  erect  position,  and  the  urine  evacuated,  rests 
against  the  neck  of  the  organ,  and  sometimes  even  projects  into 
tlie  orifice  of  the  urethra. 

Cases  occur  in  which  the  concretion  is  alternately  loose  and 
fixed.  This  may  be  owing  to  several  circumstances,  of  wliich 
the  most  constant,  perhaps,  is  the  existence  of  an  abnormal  pouch. 
The  foreign  body  may  also  be  arrested  in  the  folds  of  the  mucous 
membrane,  in  the  depression  behind  the  pi'ostate,  or  an  inter- 
ureteral  bar,  in  the  substance  of  the  prostate,  in  the  orifice  of 
the  ureter,  or  in  the  mouth  of  the  urethra. 

Vesical  calculi  may  become  permanent!}'  adherent,  attached, 
or  fixed.  This  may  take  place  in  different  ways,  and  under  a 
variety  of  circumstances.  The  following  may  be  mentioned  as 
the  most  important :  1.  An  effusion  of  coagulating  lymph.  2. 
The   formation  of  an  abnormal   pouch  ;    3.  The  existence  of  a 


188  STOXE    IN    THE    BLADDER. 

jtaytillaiy  or  polypoid  tumor;  4,  A  bilobed  state  of  the  Ijladdor; 
5.  The  i)rojection  of  the  concretion  into  the  ureter,  or  some  other 
passage;   6.  Its  lodgment  in  the  Avail  of  the  bladder. 

1.  The  continual  irritation  caused  by  the  presence  of  a  calculus 
may  lead  to  an  effusion  of  coagulating  lymph,  the  quantity  of 
which,  however,  is  rarely  considerable.  When  this  substance 
possesses  a  good  deal  of  plastic  power,  it  may  become  organized, 
notwithstanding  the  heterogeneous  character  of  the  urine  with 
which  it  is  incessantly  in  contact.  Abnormal  bands  ma}'  thus 
l)e  formed,  by  which  the  foreign  body  is  tied  to  the  inner  surface 
of  the  bladder,  and  permanently  retained  in  its  place. ^  Or  the 
quantity  of  lymph  poured  out  may  be  so  great  as  to  surround 
and  almost  bury  the  concretion.  In  either  case,  its  extraction 
may  be  attended  with  much  difficulty. 

2.  Sometimes  the  calculi  are  contained  in  distinct  cysts,  sacs, 
or  pouches,  formed,  in  rare  instances,  l)y  parietal  abscesses  which 
have  opened  internally,  or,  as  more  frequently  happens,  and  as 
has  been  already  seen.  In'  a  protrusion  of  the  mucous  membrane 
across  the  muscular  fibres  of  the  bladder.  The  volume  of  the 
incarcerated  concretion  is  seldom  large,  nor  is  it  often  that  more 
than  one  is  contained  in  one  pouch.  I'^.very  sac,  however,  even 
if  there  be  a  considerable  number,  may  be  occupied  l)y  a  stone. 

One  of  the  most  l)eautiful  and  interesting  specimens  of  saccu- 
lated calculi  of  the  bladder,  of  Avhieh  I  have  any  knowledge, 
is  represented  in  fig.  49,  copied  from  a  draAving,  made  for  me, 
by  Dr.  A.  Peticolas,  fbrmerlj'  Demonstrator  of  Anatomy  in  the 
Medical  College  at  Richmond,  Virginia.     The  individual  fromj 
whom  it  was  removed  had  been  a  patient  of  Dr.  T.  Johnson,  of  I 
that  city,  Avho  had  known  him  for  several  years,  and  attended  j 
him  during  his  last  illness.     From  the  history  of  the  case,  as  I 
giAJ'en  by  this  gentleman,  I  learn  that  he  Avas  an  old  intemperate 
pau[ier,  who  at  the  time  of  his  admission  into  the  almshouse  at 
Richmond,  about  ten  da^-s  before  he  died,  Avas  A^ery  feeble,  but 
free  from  pain  and  fever;  his  ahnne  and  urinary  discharges  were 
regular,  and  he  had  never,  so  far  as  could  be  ascertained,  passed 
any  calculi  either  before  or  daring  his  present  illness.     Tie  was! 
allowed  wiiiskev  and  a  generous  diet,  but  took  no  medicine. 

On  exHiuining  the  bodj-,  Dr.  Johnson  found  a  tablespoonfnl, 

'  Peiiusyhaiiia  Hospital  Reports,  vol.  ii.,  18G1\  p.  40. 


SITUATION. 


189 


or  more,  of  calculi  lying  loosely  in  the  bas-fond  of  the  bladder. 
The  whole  internal  surface  of  the  organ  was  studded  with  con- 
cretions, vvliich  were  contained  in  distinct  sacs,  hut  from  which 
most  of  til  em  could  be  easih*  removed.  Many  small  and  some 
large  ones,  the  latter  as  much  as  three-eighths  of  an  inch  in 
diameter,  were  completely  encj'sted.  The  bladder  was  unusually 
large,  the  fundus  mounting  above  the  brim  of  the  pelvis.  The 
left  kidney  contained  an  abscess,  which  had  not  yet  discharged 
its  contents.  The  cephalic  and  thoracic  organs  were  normal,  as 
were  also  most  of  the  abdominal. 

Fiff.  49. 


Sitcculaled  raliuli. 


3.  A  stone  may  become  fixed  by  a  papillary  growth  of  the 
bladder.  This  occurrence,  although  rare,  has  been  noticed  by 
different  observers.  The  most  common  situation  of  this  morbid 
growth  is  the  trigone  of  the  organ,  where  it  may  acquire  a 
volume  ranging  between  that  of  a  marble  and  that  of  a  pullet's 
Qgg.     When  the  stone  is  unusually  rough,  knobby,  or  spinous. 


190  STOXE    IX    THE    BLADDER. 

an  attacliment  may  easily  be  formed  between  it  and  tbe  tumor, 
by  the  processes  which  the  Latter  sends  into  the  openings,  or 
around  the  projections  of  the  former.  The  adhesion  thus  estab- 
lished may  be  very  firm,  especially  if  there  be  at  the  same  time 
a  considerable  effusion  of  lymph. 

4.  A  bilobed  state  of  the  bladder  is  sometimes  observed,  the 
organ  consisting,  as  the  name  implies,  of  two  compartments,  of 
which  the  smaller  one  is  usually  above  the  other,  A  very  in- 
structive case  of  congenital  bifid  bladder,  complicated  by  the 
presence  of  a  calculus,  has  been  reported  by  Dr.  Scarenzio.'  A 
calculus,  developed  in  the  lesser  pouch,  may  not  be  able  to  pass 
into  the  larger,  in  consequence  of  the  small  size  of  the  opening 
of  connnunication,  and  may,  therefore,  be  regarded  as  extra- 
vesicular.     * 

5.  A  stone  may  become  permanently  impacted  by  projecting 
into  the  urethra,  the  ducts  of  the  prostate,  the  orifices  of  the 
ejaculatory  ducts,  or  the  outlet  of  the  ureter.  The  latter  accident 
may  happen  in  consequence  of  the  imperfect  descent  of  the  con- 
cretion, or  the  calculus  may  be  developed  in  the  bladder,  and  be 
gradually  prolonged  into  the  tube.  In  a  few  rare  instances,  the 
stone  has  been  known  to  project  into  both  ureters  as  well  as  into 
the  urethra. 

6.  The  concretion  is  occasionally  imbedded  or  encysted  in  the 
wall  of  the  bladder.  The  sabulous  matter,  in  this  case,  is  proba- , 
bly  deposited  originally  in  a  mucous  follicle,  where  it  gradually  I 
augments  in  quantity,  and  effects  a  secure  lodgment  by  raising 
the  mucous  membran-e  over  its  surface,  and  contracting  firm  ad- 
hesions to  the  muscular  fibres  beneath.  Several  such  calculi  are 
represented  in  fig.  50.  In  general,  the  concretions  are  small, 
though  they  have  been  known  occasionally  to  acquire  a  con- 
siderable bulk.  In  their  number,  they  may  vary  from  one  to 
half  a  dozen  or  even  more.  An  example  has  been  recorded  in 
which  a  calculus  was  lodged  between  the  coat^  of  the  bladder. 

7.  Finally,  the  calculous  matter,  instead  of  being  collected  into 
a  distinct  concretion,  is  sometimes  spread  out  in  the  form  of  a 
layer  upon  the  bas-fond  of  the  bladder.  The  crust  thus  formed 
is  of  variable  extent,  and  ranges  from  the  merest  lamella  to  a 
mass  several  lines  thick.     In  the  latter  case,  it  generally  exhibits 

'  Annali  Universal!  di  j\leclicina,  1860,  Dicbr.,  vol.  174,  p.  ')'3l. 


SYMPTOMS. 


191 


a   concentric,   stratiform    arrangement.      Its    adhesion    to   tlie 
l)ludder  is  sometimes  so  firm  as  to  render  it  difficult  for  the  sur- 


Fiff.  50. 


:sir--__^ 


Encysted  Calculi.  • 

geon  to  break  it.  A  layer  of  this  kind,  of  considerable  thick- 
ness, now  and  then  forms  around  a  villous  or  fibrous  tumor  of 
the  bladder.  When  the  calculous  matter  presents  this  peculiar 
arrangement,  it  grates  under  the  instrument,  and  can  be  dis- 
tinctly felt  through  the  rectum.  When  struck  with  the  sound, 
it  emits  a  peculiar  noise,  not  unlike  that  of  a  cracked  pot.  I 
hare  seen  several  specimens  in  which  this  lamelliform  arrange- 
ment coexisted  with  separate  calculi. 


Sect.  IV  —SYMPTOMS. 

The  symptoms  of  stone  in  the  bladder  may  be  conveniently 
divided  into  the  rational  and  physical  ;  or  into  those  which  are 
furnished  by  the  suffering  organ  and  the  parts  in  its  immediate 
vicinity,  and  those  which  are  derived  by  the  surgeon  from  a 
careful  manual  exploration.  They  may  be  divided,  moreover, 
into  local  and  general,  as  they  afi^ect  the  urinary  apparatus,  or 
the  system  at  large. 

The  rational  symptoms,  which  may  be  considered  first,  are 
not  only  numerous  but  considerably  diversified  in  their  character. 
They  may  be  thus  enumerated  :  Puin  in  making  water,  especially 
when  the  last  drops  are  expelled,  felt  both  in  the  bladder  and  the 
associated  parts ;  a  sense  of  weight  and  uneasiness  in  the  pelvis, 
anus,  and  perineum  :  frequent  micturition  ;  an  occasional  inter- 
ruption of  the  stream  of  urine  ;  pain  and  itching  in  the  head  of 
the  penis,  with  smarting  or  pricking  sensations  in  the  urethra, 
particularly  at  its  orifice ;  enlargement  of  the  penis  and  elonga- 


192  STONE    IX    THE    BLADDER. 

tion  of  tlie  prepuce  ;  occasional  priapism,  with  or  witliont  sexual 
desire ;  an  increased  secretion  of  mucus  from  the  lining  mem- 
brane of  the  bladder ;  a  bloody  state  of  the  urine  ;  incontinence 
of  urine;  prolapse  of  the  rectum;  spmpathetic  suffering;  and, 
linally,  the  noise  furnished  by  the  calculi  knocking  against  each 
other  in  the  bladder. 

The  above  symptoms  usually  come  on  gradually,  and  a  con- 
siderable period  often  elapses  before  the  patient  is  led  to  suspect 
the  real  nature  of  his  condition.  This  is  especially  the  case 
when  the  general  health  is  good,  and  the  bladder  perfectly  sound. 
Indeed,  under  such  circumstances,  the  organ  may,  for  a  long 
time,  take  no  cognizance  of  the  presence  of  the  foreign  body. 
Gradually,  however,  marks  of  the  disease  are  developed,  and 
assume  such  a  character  as  hardly  to  admit  of  being  misinter- 
preted. Pain  is  felt  at  the  neck  of  the  bladder,  reflected  along  the 
course  of  the  urethra,  and  particularly  severe  during  the  emission 
of  the  last  drops  of  w^ater  ;  the  desire  to  urinate  is  more  frequent 
than  natural,  and  the  effort  to  resist  it  more  unavailing;  there  is 
a  sense  of  weight  or  uneasiness  in  the  perineum  and  anus  ;  the 
stream  of  urine  is  often  suddeidy  interrupted  ;  more  or  less  dis- 
tress is  experienced  in  the  head  of  the  penis;  and,  finally,  every 
attempt  at  micturition  is  attended  with  straining  and  tenesmus. 
To  these  symptoms  are  gradually  superadded  most,  if  not  all,  of 
those  above  indicated.  No  regularity  or  uniformity,  however, 
is  witnessed,  as  a  general  rule,  in  the  manner  of  their  appearance. 
AVe  may  next  proceed  to  examine  the  most  characteristic  of 
these  symptoms  in  detail. 

o.  Pain. — Although  sometimes  absent,  pain  is  usually  one  of 
the  earliest  and  most  characteristic  symptoms  of  stone  in  the 
bladder.  It  is  conmionly  of  a  sharp,  darting,  pricking,  or 
burning  nature,  and  is  felt  most  keenly  at  the  neck  of  the 
bladder  and  in  the  urethra,  at  the  posterior  portion  of  the  head 
of  the  penis,  during,  but  more  particularly  at  the  completion  of, 
micturition,  in  consequence  of  the  bladder,  contracting  tightly 
on  the  calculus  and  impelling  it  against  its  sensitive  neck.  The 
reflected  pain  in  the  head  of  the  penis,  which  is  often  a  source 
of  great  suffering,  is  much  more  frequent  and  severe  in  the 
young  and  middle-aged  than  in  the  old,  in  wdiom  it  is  sometimes 
very  slight.  It  is  seldom  absent  in  any  case.  To  mitigate  this 
distress,  the  patient  soon  acquires  the  habit  of  forcibly  grasping 


SYMPTOMS.  193 

the  penis,  and  not  only  compressing  it,  but  pulling  it  to  obtund 
its  sensibility.  The  habit  finally  becomes  confirmed,  and  hence 
it  is  not  unusual  with  this  class  of  sufterers  to  have  the  hand 
constantly  in  the  pocket  and  keep  it  employed,  in  consequence 
of  which  the  penis  is  rendered  not  only  unnaturally  large,  but 
the  whole  organ  is  increased  in  volume,  and  the  prepuce  more 
or  less  thickened  and  elongated.  Frequent  priapism,  with  or 
without  sexual  desire,  also  takes  place,  and  is  sometimes  wit- 
nessed in  the  most  tender  infants. 

The  pain  is  generally  aggravated  by  rough  exercise ;  by  pres- 
sure on  the  hypogastrium;  hy  distention  of  the  rectum;  and 
even  by  a  mere  change  of  the  position  of  tlie  body.  It  is  also 
considerably  influenced  by  the  form  and  volume  of  the  concre- 
tion, the  condition  of  the  mucous  membrane  of  the  bladder,  the 
temperament  of  the  patient,  and  the  state  of  the  general  health. 
A  voluminous  or  rough  stone  causes  more  suflering  than  a  small 
or  smooth  one.  In  exceptional  instances,  how^ever,  when  the 
concretion  is  studded  with  spinous  projections,  the  pain  is  very 
slight,  probably  because  they  admit  of  the  more  ready  passage 
of  the  urine.  An  inflamed,  ulcerated,  or  hypertrophied  bladder 
is  less  patient  of  its  contents  than  a  comparatively  healthy  one. 
A  nervous  temperament,  an  irritable  state  of  tlie  system,  a  gouty 
or  rheumatic  diathesis,  and  intemperance  of  any  kind,  materially 
increase  the  local  suffering. 

An  adherent  or  encysted  calculus,  or  one  contained  in  a  pouch 
behind  an  interureteral  bar  or  an  enlarged  prostate,  rarely  occa- 
sions much  pain.  Old  men  who  never  completely  empty  the 
bladder,  and  persons  affected  with  atony  or  paralysis  of  this 
organ,  sufter  little  from  this  disease.  Finally,  the  pain  may  be 
reflected  to  the  neighboring  parts,  as  the  testicles,  scrotum,  anus, 
thighs,  groins,  and  even  the  kidneys.  One  or  both  testicles 
often  become  painful,  and  are  commonly  retracted  when  there  is 
a  severe  fit  of  suffering. 

/3.  Alterations  in  the  Act  of  Micturition. — A  very  prominent, 
early,  and  constant  symptom  of  this  disease  is  a  frequent  desire 
to  urinate.  Instead  of  passing  his  water  four  or  five  times  in 
the  twenty-four  hours,  the  patient  is  perhaps  obliged  to  void  it 
every  hour  and  a  half  or  two  hours.  In  some  instances,  indeed, 
the  calls  to  make  water  are  almost  incessant,  and  what  increases 
the  distress,  in  such  cases,  is  the  inability  to  resist  them.  This 
13 


104  STONE    IX    THE    BLADDEK. 

symptom,  wliicli  is  liable  to  be  greatly  aggravated  by  certain 
states  of  the  urinary  apparatus,  as,  for  example,  an  ulcerated 
condition  of  the  lining  membrane  of  the  bladder,  hypertrophy 
of  the  prostate  gland,  or  stricture  of  the  urethra,  generally  exists 
at  a  very  early  jjeriod  of  the  disease,  when  the  stone,  perhaps, 
has  not  yet  acquired  the  bulk  of  a  cherry.  It  evidently  depends 
upon  a  morbid  sensibility  of  the  neck  of  the  bladder,  caused  by 
the  frequent  contact  of  the  foreign  body,  and  is  always  increased, 
or  temporarily  aggravated,  during  the  day  when  the  patient  is 
walking  about,  by  rough  exercise,  by  the  operation  of  sounding, 
the  use  of  drastic  purgatives,  and  various  other  causes;  while  it 
is  decreased  at  night  when  the  patient  is  in  bed. 

Another  very  valuable,  because  a  very  constant  symptom  of 
stone  in  the  bladder,  is  a  sudden  interruption  of  the  flow  of 
urine.     This  is  so  common  an  occurrence  that  it  may  be  regarded 
almost  as  pathognomonic.     It  is  caused  by  the  falling  of  the 
concretion  against  the  neck  of  the  bladder,  thereby  producing  a 
partial  or  complete  occlusion  of  the  oritice  of  the  urethra.     It 
generally  makes  its  appearance  early  in  the  disease,  and  is  often 
one  of  the  first  symptoms  that  attracts  attention.     As  it  may 
occasionally  be  absent    during  urination,  so  it  may  sometimes] 
come  on  repeatedly  during  the  same  act.     The  interruption  thus 
caused,   although    generally    momentarj',   may   endure   several 
minutes,  or  even  much   longer.     A  change  of  posture,  gentle! 
pressure  on  the  hypogastric  region,  anus,  or  jierineum,  or  rest  for 
a  few  minutes  on  the  back,  usually  sufiice  to  dislodge  the  stone, 
and  to  free  the  oritice  of  the  urethra.     Occasionally,  however,  it  I 
happens  that  the  calculus  is  firmly  impacted  in  this  canal,  and 
then  the  stoppage  amounts  to  a  real  retention,  requiring  the  use, 
of  the  catheter  to  push  the  intruder  out  of  the  way. 

To  avert  pain  by  preventing  the  stone  from  interrupting  the! 
stream  of  urine,  or  by  reinviting  the  flow  when  it  has  been! 
arrested,  a  stooping  posture  is  usually  adopted  during  micturi- 
tion ;  but  not  infrequently,  the  patient  is  obliged  to  place  him- 
self in  a  particular  attitude.  Thus,  he  sometimes  crosses  ori 
separates  his  legs,  inclines  his  body  to  one  side,  lies  down,  bends  ^ 
forwards,  or  supports  himself  upon  his  knees  and  elbows;  some-j 
times  he  leans  over  and  rests  on  his  head.  One  of  my  patientsJ 
a  lad,  five  years  old,  was  constantly  in  the  habit,  when  passing! 
his  water,  of  lying  on  his  back  and  throwing  his  buttocks  up  in 


SYMPTOMS.  195 

the  air.  Professor  Eve/  of  l^ashville,  lithotomized  a  man,  who, 
for  two  years  previously  to  the  operation,  was  obliged,  whenever 
he  wished  to  urinate,  to  assume  the  horizontal  posture,  and  push 
up  the  bladder,  which  contained  one  hundred  and  seventeen 
calculi,  with  his  fingers  in  the  rectum. 

Incontinence  of  urine,  not  constant,  or  even  frequent,  but 
occasional,  is  another  symptom  of  this  disease.  It  may  be  pro- 
duced by  several  causes,  of  which  the  principal  are,  first,  the 
presence  of  an  unusually  large  stone,  filling  nearly  the  whole  of 
the  bladder;  secondly,  a  loss  of  power  of  the  sphincter  muscle; 
and,  thirdly,  the  partial  obstruction  of  the  orifice  of  the  urethra, 
by  the  intromission  of  the  foreign  body.  The  urine,  in  all  these 
cases,  may  dribble  awaj^  incessantly,  or  it  may  be  detained  for 
some  time,  and  then  pass  ott'  involuntarily. 

y  Changes  in  the  Urine. — A  very  common  attendant  upon 
stone  is  an  inordinate  secretion  of  mucus  or  muco-pus.  This, 
like  some  of  the  other  symptoms  already  referred  to,  may  be 
entirely  absent ;  but  it  usually  shows  itself  at  a  variable  interval 
during  the  progress  of  the  malady. 

Hematuria  is  sometimes  observed,  particularly  in  the  old  and 
middle-aged,  and  is  often  directly  traceable  to  the  effects  of 
rough  exercise,  when  it  becomes  a  symptom  of  some  importance. 
The  amount  of  blood  poured  out  by  the  ruptured  capillaries 
seldom  amounts  to  more  than  a  few  drops,  which  are  expelled 
with  the  last  drops  of  urine.  The  sanguinolent  appearance  may 
last  several  days ;  but  it  generally  promptly  subsides  under  the 
influence  of  the  recumbent  position  and  demulcent  drinks. 

The  constitutional  effects  of  stone  vary  considerably  in  differ- 
ent cases,  and  under  different  circumstances.  At  the  commence- 
ment of  the  disease,  the  general  health,  in  the  great  majority  of 
instances,  is  but  little,  if  at  all,  impaired  ;  this  is  particularly 
true  of  children,  who,  although  suffering  severe  local  distress, 
often  retain  their  flesh  and  good  looks  in  a  remarkable  degree, 
showing  that  their  assimilative  powers  are  in  excellent  condition. 
In  some  cases,  however,  the  system  feels  the  effects  of  the  local 
mischief  at  an  early  period,  and  in  the  more  advanced  stages  it 
rarely  entirely  escapes.  Young  men  and  old  subjects  usually 
suffer  more  than  children.     When  the  affection  is  simple,  the 

'  Soutliera  Med.  and  Surg.  Journal  for  1849. 


196  STOXE    IN    THE    BLADDER. 

constitutional  symptoms  are  generally  slight,  compared  with 
what  they  often  are  wlien  it  is  complicated  with  serious  lesion 
of.  the  urinary  organs,  especially  of  the  bladder  and  the  kidneys. 
Under  such  circumstances,  the  general  health  is  commonly 
severely  deranged ;  the  patient  is  thin  and  wan;  the  countenance 
is  expressive  of  deep  distress ;  the  pulse  is  small,  frequent,  and 
irritable ;  the  skin  is  dry  and  husky,  and  exhales  a  peculiar 
urinous  odor ;  the  surface  is  remarkably  susceptible  to  external 
impressions ;  the  sleep  is  disturbed  at  night ;  the  appetite  is  im- 
paired ;  the  stomach  is  harassed  with  sour  eructations ;  the  bowels 
are  irregular ;  the  urinary  secretion  is  vitiated  ;  and  the  extremi- 
ties are  constantly  cold.  When  the  disease  exists  in  its  worst 
form,  the  symptoms  here  enumerated  become  greatly  aggra- 
vated ;  and  the  patient  is  gradually  worn  out  by  hectic  irritation, 
accompanied  by  night-sweats  and  colliquative  diarrhoea.  The 
duration  of  the  disease,  from  its  commencement  to  its  iinal  ter- 
mination in  death,  varies  in  difterent  cases,  and  under  difl'erent 
circumstances,  from  eighteen  months  to  ten,  fifteen,  twenty,  and 
even  thirty  years. 

The  symptoms  of  this  disease,  after  having,  perhaps,  existed 
for  a  long  time  in  an  aggravated  form,  are  occasionally  com- 
pletely arrested,  or  so  much  mitigated  as  to  induce  the  patient 
to  believe  that  he  is  well.  The  pain  diminishes,  micturition  is 
rendered  more  easy,  and  the  general  health  decidedly  improves. 
In  this  way  the  case  progresses  for  weeks,  perhaps,  indeed,  for 
months,  when  all  of  a  sudden,  in  consequence,  it  may  be,  of 
exposure  to  cold,  or  some  irregularity  of  the  diet,  the  disease 
returns  with  its  wonted  violence ;  the  urine  assumes  a  turbid, 
purulent,  or  lactescent  aspect ;  fever  sets  in ;  the  tongue  is  covered 
with  a  whitish  fur ;  the  digestive  function  is  disturbed;  the  face 
becomes  pale  and  wan  ;  rapid  emaciation  takes  place ;  and  death 
at  length  relieves  the  poor  patient  of  all  his  troubles.  In  other 
cases,  the  symptoms  recur  in  a  very  mild  form,  and  the  patient 
lives  for  years  in  comparative  comfort.  The  causes  of  these 
changes  are  seldom  appreciable. 

Finally,  it  should  not  be  forgotten,  that  in  addition  to  the 
reflex  pains  experienced  in  the  associated  parts  of  the  urinary 
organs,  suttering  is  sometimes  perceived  at  parts  very  remote 
from  the  seat  of  the  disease.     Dr.  Marshall  Hall'  had  a  case  in 

'  Diseases  of  the  Nervous  System,  London,  1841,  p.  339. 


PHYSICAL    SIGNS,   SOUNDING,    DIAGNOSIS.  197 

wliich  a  stone  in  the  bladder  caused  spasmodic  stricture  of  the 
sphincter  muscle  of  the  anus.  The  contraction  was  so  great  as 
scarcely  to  admit  of  the  introduction  of  the  finger.  The  moment 
the  calculus  was  removed,  the  reflected  irritation  ceased.  Pains, 
with  numbness  and  tingling,  have  also  been  experienced  in  the 
heel,  knee,  or  foot.  An  English  nobleman  suffered  from  pain  in 
the  left  arm,  for  which  his  professional  attendants  were  for  a 
long  time  unable  to  account.  Upon  introducing  a  sound,  the 
true  nature  of  the  case  was  detected,  the  stone  was  removed, 
and  the  trouble  ceased.'  A  still  more  remarkable  instance 
of  sympathetic  disturbance  in  consequence  of  the  irritation 
of  the  vesical  nerves  by  a  calculus,  is  one  of  epilepsy,  which 
came  under  the  observation  of  Dr.  John  Duncan,  of  Scotland. 
A  boy,  five  years  of  age,  had  been  suffering  all  his  life  from  in- 
continence, pain  in  the  bladder,  and  other  symptoms  of  stone. 
For  upwards  of  two  years  he  had  frequent  attacks  of  epilepsj^, 
which  continued  with  more  or  less  severity,  until  about  a  fort- 
night after  he  was  lithotomized,  when  they  permanently  dis- 
appeared. 

Sect.  V.— PHYSICAL  SIGNS,  SOUNDING,  DIAGNOSIS. 

When  the  symptoms  above  described  are  all  present,  or  even 
when  several  of  them  are  absent,  there  is  a  strong  probability 
that  the  patient  is  laboring  under  stone  of  the  bladder,  and  this 
probability  is  converted  into  certainty,  when  the  surgeon  is  able 
to  feel  and  hear  the  foreign  body.  ^Nevertheless,  as  Avill  be  sub- 
sequently seen,  cases  occasionally  occur,  in  which,  notwithstand- 
ing the  existence  of  both  the  rational  and  phj^^sical  signs,  no 
concretion  is  to  be  discovered.  On  the  other  hand,  a  stone  may 
apparently  have  been  detected,  and  yet  when  the  patient  comes 
to  be  cut,  no  stone  is  found.  Instances  of  both  these  occurrences 
have  been  repeatedly  met  with,  and  that,  too,  in  the  hands  of 
the  most  experienced  and  accomplished  lithotomists.  To  remove, 
therefore,  all  doubt  upon  the  subject,  no  matter  how  clearly 
marked  may  be  the  rational  symptoms,  it  is  always  necessary, 
as  a  preliminary  step,  to  resort  to  sounding.  Tliis  consists 
in  introducing  into  the  bladder  an  instrument,  fig.  51,  shaped 

'  Hunter's  Works,  edited  by  Palmer,  vol.  i.  p.  321. 


198 


STONE    IX    THE    BLADDER. 


Fis;.  51. 


Fiff.  52. 


somewhat  like  a  catheter,  and  either  solid  or  hollow,  with  which 
the  cavity  of  the  organ  is  explored  in  every  possible  direction, 
and  in  the  most  patient,  thorough  manner.  The  instrument 
itself  is  called  a  sound. 

Sounds  vary  in  their  construction,  in  their  size,  and  in  the 
materials  of  which  they  are  composed.  The  best  are  solid, 
made  of  steel,  and  plated  with  nickel,  with  varying  degrees  of 
curvature.  For  an  adult,  the  length,  from  one  extremity  to  the 
other,  should  be  about  twelve  inches,  of  which  two  inches  and 
a  half  should  be  allowed  for  the  handle.     Children,  of  coui*se, 

require  a  shorter  instrument.  Generally 
speaking,  a  shaft  of  moderate  diameter 
is  preferable  to  one  of  large  size,  as  it 
does  not  distend  the  parietes  of  the 
urethra,  and  is  consequently  much  more 
easily   moved    about    in    the    bladder. 

^l|  The  vesical  extremity,  or  beak,  should 

be  about  an  inch  long,  be  more  abruptly 
curved  than  that  of  an  ordinary  catheter, 
and  be  several  sizes  larger  than  the  shaft. 
With  an  instrument  constructed  on  these 
principles,  every  portion  of  the  bladder 
may  be  explored  wdth  facility. 

Some  lithotomists  prefer  the  ordinary 
silver  catheter  to  the  instrument  now 
described,  on  the  ground  that  it  is  more 
convenient  wdien  it  is  necessary  to  inject 
the  bladder  or  draw  oif  the  urine.  This 
is  undoubtedly  an  advantage,  which  is 
not  compensated,  however,  by  the  dis- 
advantages of  the  more  obscure  noise 
and  sensation,  which  such  an  instrument 
yields  from  its  contact  with  the  calculus. 
An  excellent  substitute  for  the  catheter 
is  the  hollow  sound,  represented  in  fig. 
52,  which,  by  permitting  the  gradual 
escape  of  the  urine,  greatly-  facilitates  the  detection  of  the  con- 
cretion. 

Previously  to  sounding,  the  bowels  should   always  be  Avell 
cleared  out  with  castor  oil,  or  a  purgative  enema,  in  order  that 


Sonnd. 


Hi.llow  Sound. 


PHYSICAL    SIGXS,    SOUNDING,   DIAGNOSIS.  199 

there  may  be  no  obstruction  in  the  rectum  to  impede  the  move- 
ments of  the  instrument,  or  interfere  \y\th  the  free  phiy  of  the 
finger,  sliould  its  introduction  into  the  gut  become  necessary, 

A  patient  is  never  sounded  when  the  bladder  is  empty.  In 
this  condition  the  organ  is  apt  to  contract  upon  its  contents,  and 
may  so  prevent  the  instrument  from  moving  about  with  that 
freedom  which  is  so  necessary  for  detecting  the  stone.  The 
quantity  of  water  wdiich  the  bhidder  should  contain  must  vary 
according  to  circumstances,  as  the  capacity  of  the  organ  and  the 
size  of  the  concretion ;  but,  in  general,  it  need  not  exceed  three 
or  four  ounces.  If  the  urine  is  too  abundant,  there  is  dano;er 
that  the  stone,  especially  if  it  be  small,  will  be  lost  in  the  fluid, 
and  thus  elude  the  sound.  I  have  repeatedly  met  with  cases 
where  the  bladder  was  so  irritable  as  to  be  hardly  able  to  retain 
any  urine,  even  for  a  few  minutes.  Under  such  circumstances, 
and  also  wdiere  the  patient  has  urinated  inadvertently,  the 
requisite  distention  should  be  produced  by  the  injection  of  tepid 
water  through  the  hollow  sound. 

During  the  operation,  the  |iatient  should  lie  upon  his  l)ack, 
near  the  edge  of  the  bed,  with  his  head  and  shoulders  somewhat 
elevated,  and  the  lower  extremities  slightly  flexed  and  separated, 
to  relax  the  abdominal  muscles.  The  surgeon  takes  his  position 
at  the  left  side  of  the  patient,  warms  and  oils  the  instrument, 
and  introduces  it  in  the  same  manner,  and  with  the  same  pre- 
cautions as  when  he  introduces  the  lithotrite. 

Frequently  the  sound  encounters  the  stone  the  moment  it 
enters  the  neck  of  the  bladder ;  but  should  this  not  happen,  it 
must  be  passed  farther  in,  and  moved  about  in  different  direc- 
tions until  the  object  is  accomplished.  To  explore  the  lateral 
parts  of  the  bladder,  the  instrument  must  be  rotated  upon  its 
axis,  first  on  one  side,  and  then  on  the  other.  The  bas-fond  of 
the  organ  is  best  examined  by  reversing  the  beak  of  the  sound, 
and  elevating  the  handle.  The  anterior  or  pubic  surface  of  the 
bladder  can  be  reached  only  by  an  instrument  with  a  very  long- 
curve,  or  by  depressing  the  ordinary  sound  between  the  patient's 
thighs,  while  the  bladder  is  forced  downwards  by  the  left  hand 
over  the  hypogastrium.  Very  frequently  the  stone  cannot  be 
felt,  in  consequence  of  its  lying  in  a  pouch  just  behind  the 
prostate  gland.     When  this  is  the  case,  the  index  finger  of  the 


200  STOXE    IX    THE    BLADDEE. 

left  hand,  properly  oiled,  is  introduced  into  the  rectum,  and  the 
foreign  body  puslied  forward  from  its  lurking-place  against 
the  reversed  sound.  Sometimes  it  is  necessary  to  change  the 
position  of  the  patient,  making  him  lie  on  his  side,  sit  or  stand, 
bend  forward,  or  raise  his  buttocks.  Dr.  Physick  occasionally 
placed  his  patients  nearly  on  their  head,  so  as  to  render  the 
fundus  of  the  bladder  the  most  dependent  portion  of  the  viscuti. 
Indeed,  every  variety  of  expediency  is  sometimes  required  to 
enable  us  to  accomplish  the  object  of  this  preliminary  operation. 
Children  often  greatly  embarrass  us  by  their  cries,  as  well  as 
their  strugo-les ;  but  these  sources  of  annoyance  may  be  eifectually 
counteracted  by  the  use  of  chloroform,  which  I  am  in  the  habit 
of  employing  in  nearly  all  cases  of  the  kind,  for  the  purpose 
of  preventing  pain,  calming  the  patient's  mind,  and  quieting  the 
bladder. 

The  noise  and  sensation  communicated  by  sounding  are  pecu- 
liar. The  noise  is  a  sort  of  click,  or  clear  metallic  resonance, 
which  is  caused  by  the  contact  of  the  stone  and  the  instrument, 
and  which  no  other  bodies  in  the  bladder  can  produce.  It  is, 
therefore,  in  the  highest  degree  valuable  as  a  diagnostic  sign. 
It  may  often  be  perceived  at  a  distance  of  several  yards  from  the 
patient,  and  is  generally  more  distinct  and  clear  when  the  stone 
is  composed  of  uric  acid  or  oxalate  of  lime,  than  when  it  is  of  a 
phosphatic  nature,  when  the  sound  is  faint  and  dull.  The  click 
may  be  rendered  more  audible  by  attaching  the  sounding-board 
of  Mr.  L'Estrange  to  the  handle  of  the  instrument.  The  sensa- 
tion communicated  to  the  hand  is  likewise  liable  to  considerable 
diversity.  When  the  calculus  is  diminutive,  it  is  generally 
proportionately  faint,  and  indicative  of  a  want  of  resistance  on 
the  part  of  the  body  touched  ;  if,  on  the  other  hand,  the  concre- 
tion is  large  or  of  medium  bulk,  the  instrument,  in  encountering 
it,  receives  a  sort  of  shock  which  is  rapidly  and  forcibly  com- 
municated to  the  hand,  and  is  so  characteristic  that  it  can  never, 
Avhen  once  perceived,  be  mistaken.  A  grating,  rubbing,  or  fric- 
tion sensation  is  sometimes  distinguished ;  but  this  is  rather 
indicative  of  a  fasciculated  state  of  the  bladder,  of  the  existence 
of  a  morbid  growth,  or  an  incrusted  condition  of  the  mucous 
membrane,  than  of  the  presence  of  a  calculus. 

Sounding  enables  the  surgeon  not  onlj'  to  detect  the  presence  of 
a  calculus  in  the  bladder,  but  it  frequently  furnishes  important 


PHYSICAL    SIGNS,   SOUNDIXG,    DIAGNOSIS.  201 

data  ill  regard  to  its  bulk,  situation,  and  consistence,  and  as  to 
whether  it  is  single  or  multiple,  rough  or  smooth,  loose  or 
attached. 

It  is  usually  not  very  difficult  to  form  a  tolerably  correct  idea 
of  the  volume  of  a  stone.  If  it  is  easily  pushed  about  by  the 
instrument,  and  lost,  as  it  were,  in  the  midst  of  the  water,  it 
may  be  inferred  that  it  is  small ;  on  the  contrary,  it  may  be 
concluded  that  it  is  quite  l)ulky,  if  it  maintains  its  position 
under  the  action  of  the  sound,  or  if  it  can  be  touched  simulta- 
neously at  a  number  of  points,  or,  what  is  the  same  thing,  if  it 
presents  a  large  surface.  A  large  calculus  is  always  easih'  felt 
by  the  tinger  in  the  rectum  ;  while  a  small  one  is  either  not  per- 
ceived at  all,  or  only  in  a  very  imperfect  manner.  Where  greater 
accuracy  in  regard  to  the  volume  of  the  calculus  is  desired  than 
can  be  obtained  by  the  more  common  met^iods  of  exploration,  a 
particular  instrument,  marked  by  the  divisions  of  the  metre,  may 
be  emfJoyed.  For  this  purpose,  a  common  lithotrite  might  be 
used,  or  the  contrivance  of  Mr.  L'Estrange,  constructed  upon 
the  same  principle.  A  similar  instrument  has  been  invented  by 
Dr.  Fleming,^  of  Dublin,  for  measuring  concretions  in  the  blad- 
der of  children. 

In  trying  to  ascertain  the  situation  of  a  stone  in  the  bladder, 
important  aid  may  be  derived  from  the  introduction  of  the 
finger  into  the  rectum,  or  vagina.  Indeed,  this  can,  in  man}' 
instances,  be  done  in  no  other  wa}'.  My  invariable  plan  is,  when 
I  sound  a  patient,  to  resort  to  this  expedient.  In  old  subjects, 
in  Mdiich  the  calculus  frequently  lodges  in  a  pouch  just  beliind 
the  prostate  gland,  its  presence  can  hardly  be  detected  without 
it.  In  children,  too,  it  is  a  most  valuable  auxiliary.  The  pelvis, 
at  this  age,  is  usually  so  short  and  narrow  that  nothing  is  more 
easy  than  to  trace  the  whole  outline  of  the  inferior  portion  of 
the  bladder,  enabling  us  frequently  at  once  to  determine  not 
only  the  situation  of  the  concretion,  but  also  whether  it  is  loose 
or  lixed,  small  or  large,  single  or  multiiJe.  When  there  is  reason 
to  suspect  that  the  stone  is  situated  in  the  fundus  of  the  bladder, 
or  just  behind  the  pubes,  it  might,  especially  if  it  be  large, •and 
the  bowels  are  perfectly  empty,  be  possible  to  detect  it  with  the 
hand,  applied  to  the  low^er  part  of  the  hypogastric  region. 

'  Dublin  Qviarteily  Journal  of  Medical  Science,  vol.  xviii.  p.  257. 


202  STONE    IX    THE    BLADDER. 

The  noise  furnished  by  the  instrument  affords  sometimes  a 
pretty  aecuriTte  knowledge  of  the  consistence,  structure,  and 
cliemical  qualities  of  the  foreign  body.  Tlie  uric  and  oxalic 
calculi,  as  previously  stated,  emit  a  clear  sound,  clink,  or  click ; 
the  phosphatic,  a  ilat  sound  ;  and  the  ammoniaco-magnesian,  a 
sound  intermediate  between  the  two. 

By  carrying  the  instrument  about  in  different  parts  of  the 
bladder,  we  may  ascertain  whether  there  is  but  one  stone  or 
whether  there  are  several,  and  even  form  a  tolerably  correct  idea 
of  their  actual  number.  "When  several  coexist  they  are  usually 
small,  and  the  sound,  upon  striking  them,  produces  a  sort  of 
clashing  sensation,  attended  with  a  rattling  noise. 

The  stone  may  be  supposed  to  be  smooth,  when  the  sound, 
brought  in  contact  with  its  surface,  glides  easily  over  it,  without 
being  impeded  in  its  progress.  If,  on  the  contrary,  it  is  rough, 
spinous,  or  tuberculated,  the  point  of  the  sound  is  liable  to 
become  arrested,  and  may  thus  impart  a  grating  sensation  to 
the  fingers.  It  has  been  already  stated  that  the  multiple  calculi 
are  nearly  always  smooth,  and  the  single  more  or  less  rough. 

"We  judge  that  the  stone  lies  loosely  within  the  bladder,  when 
it  changes  from  time  to  time  its  position,  or  migrates,  as  it  were, 
from  one  part  of  the  organ  to  another.  An  encj'stcd  or  adherent 
stone  is  always  found  in  the  same  situation,  due  allowance  being 
made  for  the  alterations  of  form,  which  the  bladder  undergoes 
from  the  presence  or  absence  of  the  urine. 

Patients  are  often  brought  to  the  surgeon  from  a  distance  to 
be  lithotomized.  When  this  is  the  case,  they  should  not  be 
sounded  until  they  have  recovered  from  their  fatigue.  Nor 
should  the  operation  be  performed  during  or  immediately  after 
a  "  fit  of  the  stone."  Indeed,  simple  as  the  operation  is,  it  should 
never  be  resorted  to  without  due  consideration.  If  it  is  important, 
as  it  is  universally  acknowledged  to  be,  to  prepare  the  system 
for  the  operation  of  lithotomy,  it  is  hardly  less  so,  in  my  judg- 
ment, to  prepare  it  for  that  of  sounding.  From  neglect  of  this 
precaution,  patients  are  often  subjected  to  much  suffering,  and 
evcH  to  great  risk.  Indeed,  there  is  reason  to  believe  that  life 
has  been  repeatedly  sacrificed  in  this  way.  Bad  consequences 
occasionally  follow,  even  when  the  utmost  care  is  taken.  I 
have  myself  witnessed  very  serious  effects  from  this  kind  of 
indiscretion,  which  has  been  followed  b}-  severe  cystitis.     Sir 


PHYSICAL    SIGNS,   SOUNDING,   DIAGNOSIS.  203 

James  Paget  has  known  death  to  ensue  from  simply  sounding 
for  stone  in  six  instances;  and  Fletcher,  Crosse,  Sanson,  Civiale, 
Horner,  and  other  surgeons,  allude  to  similar  cases. 

The  sounding  should  always  be  conducted  with  the  utmost 
gentleness,  and  should  never  be  continued  beyond  a  few  minutes 
at  a  time.  A  protracted  operation  of  this  kind  is  generally  pro- 
ductive of  mischief,  and  cannot  be  too  pointedly  condemned. 
Should  severe  pain  ensue,  it  must  be  allayed  by  a  full  anodyne  ; 
and  any  inflammatory  symptoms  which  may  arise  are  to  be  com- 
bated by  the  usual  remedies.  In  all  cases,  the  patient  should  be 
directed  to  make  free  use  of  demulcent  drinks. 

Although  sounding  is  the  onl}^  certain  method  of  detecting  a 
stone  in  the  bladder,  it  is  occasionally  liable  to  error.  Numerous 
cases  are  upon  record  where  a  foreign  body  was  supposed  to  be 
present,  and  where  the  poor  patients  were  subjected  to  all  the 
pains  and  perils  of  lithotomy,  and  yet  no  calculus  was  found, 
either  at  the  time  of  the  operation  or  after  death.  Surgeons  of 
the  most  consummate  skill  and  the  most  extensive  experience 
have  fallen  into  this  error.  Cheselden,  the  most  celebrated 
lithotoraist  of  his  age  and  country,  cut  three  patients  without 
finding  any  stone.  Blanc,  Dupuytren,  Roux,  Crosse,  T3'rrell, 
Cotta,  Yacca,  Aason,  Medoro,  Borsiori,  Ueelli,  and  Paget,  of 
Leicester,  all  operated,  expecting  to  find  a  stone,  where  there 
proved  to  be  none.  Mr.  Crosse  states  that  he  has  notes  of  not 
less  than  eight  cases  in  which  the  operation  was  needlessly  per- 
formed, and  to  several  of  wliich  he  was  an  eye-witness.  The 
late  Mr.  Samuel  Cooper,  of  London,  was  acquainted  with  the 
particulars  of  at  least  seven  such  cases,  at  two  of  which  he  was 
present.  Velpeau  says  he  has  a  knowledge  of  four  instances, 
where  the  patients  were  subjected  to  the  operation  without  there 
being  any  calculi  in  the  bladder,  and  I  myself  am  cognizant  of 
at  least  half  a  dozen  cases  in  which  this  mistake  was  committed. 
It  is  worthy  of  remark  that  a  number  of  the  patients  in  whom 
no  stone  was  found  were  promptly  and  entirely  relieved  of  the 
symptoms  which  had  been  attributed  to  its  presence.  On  the 
other  hand,  it  is  equally  certain  that  some  of  them  perished 
from  the  efi:ects  of  the  operation,  while  others  who  survived  it 
received  no  benefit  from  it. 

The  circumstances  which  may  lead  to  the  commission  of  the 
error  above  mentioned  dift'er  verv  much  in  their  character,  and 


204  STOXE    IX    THE    BLADDER. 

are  dependent  for  their  origin  either  upon  the  bladder  itself,  or 
u|ion  the  surroundino;  parts. 

Among  the  more  prominent  causes  of  error  referable  to  the 
bladder,  are  an  ulcerated'  or  indurated  and  contracted  state 
of  the  viscus ;-  the  presence  of  an  osseous  cvst  f  a  papillary*  or 
polypoid  tibroma  ;'  and  a  deposit  of  tubercular  matter.^ 

In  the  second  place,  the  surgeon  may  be  misled  by  certain  af- 
fections which  involve  the  parts  in  the  immediate  vicinity  of  the 
bladder,  as  enlargement  of  the  prostate  gland  f  hardened  and 
impacted  feces  ;-  malpositions  of  the  uterus  f  exostosis  of  the 
pelvis;  protrusion  of  the  head  of  the  thigh  bone  into  the  blad- 
der ;'°  and  an  unsually  projecting  sacrum,  in  a  very  narrow  pelvis." 

It  is  well  known  that  there  may  be  a  stone  in  the  bladder, 
and  yet  the  surgeon  be  unable  to  detect  it  by  sounding,  aided, 
perhaps,  by  all  the  auxiliar\-  means  at  his  command.  This 
failure  has  frequently  occurred,  even  where  the  concretion  has 
been  uncommonly  large,  and  where  the  operation  has  been 
repeatedly  performed  with  the  greatest  care  and  skill,  and 
varied  in  every  possible  manner.  Want  of  success  has  some- 
times attended,  even  where  the  calculi  were  multiple.  Again, 
it  has  happened  that  a  stone  has  been  promptly  detected  in  a 
iirst  sounding,  and  perhaps  not  at  all,  or  onh'  after  much  trouble, 
in  a  subsequent  one.  Or  the  reverse  of  this  may  occur,  that  is, 
the  concretion  may  elude  the  instrument  in  a  first  and  second 
sounding,  but  be  always  readily  detected  afterwards.  It  is  with 
sounding  as  with  everything  else.  To  perform  it  well  requires 
great  tact  in  the  use  of  instruments,  a  perfect  knowledge  of  the 

'  Occurred  to  Mr.  T^-rrell.     Dublin  Quarterly,  vol.  xiv.,  1852,  p.  462. 

2  Occurred  to  Clieselden  in  three  cases — Benjamin  Bell's  System  of  Surgery, 
Edin.  1784,  vol.  ii.  p.  40  ;  and  to  Blanc — Desault's  Parisian  Chirurgical  Jour- 
nal, translated  by  Gosling,  vol.  ii.  p.  12o. 

'  Occurred  to  Mr.  Middleton.     Case  referred  to  at  page  135.  ' 

*  Case  of  an  old  man  who  was  under  my  care  in  Kentucky.  I  declined  to 
operate,  and  he  was  cut  by  another  surgeon. 

'  Case  recorded  by  ilr.  Crosse.     See  Case  I.  of  table  on  page  153. 

6  Occurred  to  Dupuytren.     Lecjons  Oralcs,  t.  ii.  p.  334. 

'  Case  mentioned  by  Ripault.     Monthly  Journ.  Med.  Science,  1842,  p.  871. 

8  Case  mentioned  by  Rutti.     Traite  des  Voies  Urinaires,  p.  25. 

9  Recorded  by  Lassus — Med.  Oper.  t.  i.  p.  315  ;  and  two  cases  by  Levret, 
Jour,  de  Med.  et  de  Chir.,  Janvier,  1783,  p.  35. 

^°  Recorded  by  Uytterhoeven.     Archives  de  la  Med.  Beige,  t.  viii.  1842,  p.  44. 
"  ^Mentioned  by  Crosse.     Essay  on  Urinary  Calculus,  p.  50. 


PHYSICAL    SIGNS,   SOUNDING,    DIAGNOSIS.  205 

anatomy  of  the  urinary  apparatus,  and  a  degree  of  experience 
which  multiplied  observations  alone  can  supply.  But  the  want 
of  success,  in  this  operation,  is  not  confined  exclusively  to  the 
3'oung,  the  ignorant,  or  the  unskilful.  Men  of  the  most  con- 
summate dexterity  have  occasionally  failed  in  detecting  a  stone, 
when  a  stone  really  existed. 

Is'umerous  circumstances  may  interfere  with,  or  entirely  pre- 
vent, the  detection  of  a  vesical  calculus ;  and  hence  it  may 
become  necessary  to  examine  a  patient  not  merely  once,  but 
perhaps  many  times,  before  we  are  justiHed  in  giving  a  definite 
and  final  opinion  respecting  the  nature  of  the  case.  The  sub- 
joined arrangement  comprises  the  most  important  of  the  causes, 
which  may  prevent  the  detection  of  calculi. 

I.  Obstacles  dependent  upon  the  calculus  itself. 

a.  The  stone  may  be  unusually  small,  in  which  case  it  will  not 
only  be  more  difficult  to  detect  it,  but,  when  found,  it  will  be 
more  liable  to  glide  away  from  the  instrument,  and  so  elude  its 
contact.  The  sound  emitted  by  it  will  also  be  proportionately 
faint  and  indistinct. 

/3.  The  concretion  may  not  only  be  diminutive,  but  it  may  be 
coated  with  a  layer  of  lymph,  coagulated  blood,  or  inspissated 
mucus,  so  that  the  instrument  shall  glide  over  it  without  receiv- 
ing from  it  the  customary  impression. 

y.  A  very  bulky  stone,  without  exhibiting  anything  peculiar 
in  other  respects,  has  sometimes  eluded  the  sound.  The  prin- 
cipal reason  of  this  is  tlie  situation  of  the  foreign  body  in  a  de- 
pendent or  unusual  part  of  the  bladder,  the  size  and  form  of  the 
instrument,  or  the  manner  of  conducting  the  exploration. 

II.  Obstacles  connected  with  the  bladder. 

a.  The  calculus  may  be  sacculated,  or  contained  in  a  particular 
pouch,  formed  by  the  protrusion  of  the  mucous  membrane  across 
the  muscular  fibres  of  the  bladder,  of  which  a  good  illustration 
is  afibrded  in  fig.  53.  In  this  case,  the  foreign  body  lies  virtually 
on  the  outside  of  the  urinary  reservoir,  within  the  pelvic  cavity, 
and  may  be  so  protected  by  the  thickened  parietes  of  the  organ 
as  to  render  its  detection  utterly  impracticable  by  the  most  care- 
ful sounding.  In  an  instance  mentioned  by  Mr.  Xourse,  in  the 
forty-third  volume  of  the  London  Philosophical  Transactions, 
the  calculi,  nine  in  number,  and  contained  in  six  separate  cysts, 
were   detected    in   the   first   sounding,   but   never   afterwards. 


206 


STONE    IN    THE    BLADDER. 


Ellerus  relates  a  case  in  which  a  stone  existed  between  tlic  coats 
of  the  bladder.' 

Fig.  53. 


Sounding  for  Encysted  Stone. 

,8.  In  many  cases,  especially  in  aged  subjects,  a  pouch,  hollow, 
or  cul-de-sac,  exists  in  the  bas-fond  of  the  bladder,  immediately 
behind  the  prostate  gland,  in  which  the  calculus  may  lie  secure 
from  the  sound,  as  represented  in  fig.  54,  unless  its  beak  be 
reversed. 

Fiac.  54 


Sounding  for  Stone  behind  the  Prostate. 

r-  The  stone  sometimes  lodges  in  front  of  the  bladder,  just 
behind  the  pubes,  either  in  a  cyst,  or  attached  by  a  band  of 
lymph,  or  adherent  to  the  mucous  membrane,  as  in  fig.  55. 
When  this  happens,  it  will  be  difficult,  if  not  impossible,  to 
reach  it,  unless  the  instrument  is  unusually  long,  its  curve  un- 
commonly great,  and  its  handle  inordinately  depressed  betweer| 
the  patient's  thighs. 

'  Morgagni,  Seat  and  Causes  of  Diseases,  vol.  ii.  p.  354. 


PHYSICAL    SIGNS,    SOUNDING,    DIAGNOSIS. 


207 


5.  The  uriiiiiry  bladder  may  be  Ijilobed,  or  divided  by  a  kind 
of  diaphragm  into  two  comi)artiiients,  the  upper  of  whicli  may 
contain  a  calculus,  which  no  sound,  however  shaped  or  managed, 
may  be  able  to  reach  or  detect. 


Fia:.  55. 


SoimiliDg  for  Stone  above  the  Pubes. 


f.  When  the  bladder  escapes  into  the  groin,  as  it  does  in  certain 
forms  of  hernia,  it  may  contain  a  stone  whicli  no  sounding,  how- 
ever skilfully  conducted,  can  discover.  In  a  case  of  this  descrip- 
tion, recorded  by  T.  D.  Sala,  the  patient  had  all  the  symptoms 
of  stone,  but  no  stone  could  be  felt  during  life.  After  death,  it 
was  found  in  the  bladder,  which  had  [-assed  into  the  groin, 
Pott^  gives  a  similar  instance.  The  patient  was  a  boy  thirteen 
years  of  age,  and  the  stone  was  removed  by  incision  from  the 
groin,  where  it  had  been  confined  in  a  tirm,  strong,  white  cyst, 
connected  with  the  bladder.  Urine  passed  by  the  wound  for 
several  weeks,  but  the  cure  was  completed  in  a  month.  In  the 
female,  the  bladder  sometimes  passes  into  one  of  the  labia. 
Ilartmann^  met  with  a  case  of  this  kind  in  whicli  the  protruded 
l)art  contained  a  stone  weighing  three  ounces. 

C.  A  stone,  especially  when  small,  may  be  temporarily  lost  in 
the  folds  of  the  bladder,  and  so  elude  the  sound.  When  this 
organ  is  fasciculated,  the  foreign  body  might  be  arrested  per- 
manently in  one  of*  the  depressions  or  cavities  wdiich  are  so 
frequently  met  with  under  such  circumstances.  A  stone  so 
imbedded  would  be  likely  to  remain  small,  and  burying  itself, 
as  it  were,  beneath    the   hypertrophied  muscular  fibres  of  the 

'  Chinirgiciil  Works,  vol.  ii.  p.  397.     Phila.  1819. 
*  Eph.  Nat.  Cur,  Ann.  v.  obs.  71. 


208  STOXE    IX    THE    BLADDER. 

bladder,  would  impart  through  the  sound  a  very  faint  and  im- 
perfect sensation  to  the  hand. 

r,.  The  bladder  may  contain  too  much  or  too  little  water.  In 
the  former  case,  unless  the  stone  is  of  considerable  size,  it  will 
be  difficult  to  touch  it,  or,  if  struck,  to  obtain  the  characteristic 
feel  and  click.  It  will  fly  before  the  instrument,  and  be  lost  in 
the  midst  of  the  fluid.  If,  on  the  other  hand,  the  quantity  of 
urine  is  very  small,  the  bladder,  by  contracting  forcibly  upon 
the  concretion,  may  hold  it  firmly  in  its  grasp,  and  so  prevent  it 
from  being  satisfactorily  felt  and  heard.  In  such  a  case,  more- 
over, the  stone,  especially  if  it  be  small,  may  be  concealed  in  the 
folds  of  the  mucous  membrane. 

e.  Finally,  the  surgeon  rany  fail  in  his  attempt  to  feel  the 
stone,  in  consequence  of  an  immense  accumulation  of  blood  or 
inspissated  mucus  in  the  bladder.  From  the  same  causes,  espe- 
cially tlie  latter,  the  pain  arising  from  the  presence  of  the  con- 
cretion may  become  materially  mitigated,  particularly  if  the 
adherent  mucus  is  very  thick,  or  intermingled  with  coagulating 
lymph. 

III.  Obstacles  arising  from  the  neighboring  organs,  as  the 
ureter,  prostate  gland,  and  urethra. 

a.  The  stone  may  elude  detection  in  consequence  of  an  enor- 
mous dilatation  of  the  ureter.  The  sound  may  move  about  in 
the  abnormal  pouch  with  the  same  freedom  nearly  as  in  the 
bladder,  in  which  the  calculus  is  contained,  but  which  the  in- 
strument fails  to  enter.  Such  a  contingency,  although  very 
infrequent,  has  been  several  times  encountered  in  practice. 

fi.  The  prostate  gland,  excavated  by  disease,  as  an  ulcer  or  an 
abscess,  may  occasionally  conceal  a  small  calculus  so  as  to  pre- 
vent it  from  being  touched  by  the  sound,  or  felt  by  the  finger 
in  the  rectum.  AVhen  there  is  reason  to  suspect  such  a  condi- 
tion, the  proper  mode  of  proceeding  would  be  to  use  a  sound 
with  the  slightest  possible  curve,  and  to  push  the  calculus  out 
of  its  bed  by  inserting  the  finger  into  the  bowel. 

The  prostate  gland  is  sometimes  converted  into  an  immense 
pouch,  in  which  the  end  of  the  sound  may  be  arrested,  without 
detecting  an}-  stone,  instead  of  passing  into  the  bladder,  where 
the  foreign  body  is  actually  situated.     ]\Iuller^   mentions  the 

'  Diss.  Raram  de  Calc.  Yesic.  Observat.  Contineus,  p.  17. 


PHYSICAL    SIGNS,   SOUNDING,   DIAGNOSIS.  209 

case  of  a  bo}-,  eight  jean  of  age,  in  whom  such  a  lesion  led  to 
this  mistake.  He  was  sounded  twice  without  any  stone  being 
discovered.  The  third  time,  however,  it  was  detected,  and  the 
operation  was  accordingly  performed ;  a  large  quantity  of  pus 
escaped,  but  no  calculus  was  found.  The  patient  died,  and  on 
dissection  it  was  perceived  that  the  bladder  bad  been  converted 
into  a  ileshy  mass,  contracted  tightly  round  a  concretion  of  the 
size  of  a  small  lemon.  The  prostate  was  parth'  destroyed  by 
suppuration,  and  presented  an  enormous  cavity  into  which  the 
instrument  had  wandered  during  sounding,  and  which  had  been 
mistaken  for  the  bladder.  A  similar  case  is  mentioned  by 
Civiale.^ 

y.  Another  source  of  error  is  the  introduction  of  the  sound 
into  an  abnormal  pouch  of  the  urethra.  This  affection,  although 
infrequent,  occasionally  exists,  and  may  lead  to  deception. 
Pelletan^  saw  two  cases  which  were  mistaken  in  this  manner ; 
in  one  the  stone  was  about  the  size  of  a  pullet's  egg;  and  in  the 
other,  a  child  seven  years  of  age,  it  nearly  filled  the  bladder. 

The  symptoms  of  stone  may  be  simulated  by  reflex  irritation, 
seated  either  in  the  urinary  organs  themselves,  or  in  the  neigh- 
boring viscera.  Among  the  more  prominent  causes  of  sympa- 
thetic irritation  may  be  mentioned  irritability,  neuralgia,  spasm, 
and  simple  or  tubercular  ulceration  of  the  bladder,  inflammation 
or  calculus  of  the  kidney  or  ureter,  chronic  bypertroph}^  of  the 
prostate  gland,  stricture  of  the  urethra,  contracted  meatus, 
vascular  growths  of  the  urethra,  adherent  prepuce,  and  phimosis. 
The  latter  occurrence  is  most  common  in  boys.  Incredible  as  it 
would  seem,  vesical  calculus  may  be  simulated  by  aneurism  of 
the  abdominal  aorta,  as  in  the  interesting  case  related  b}'  Mr. 
Fenwick,^  of  England. 

The  presence  of  a  stone  in  the  bladder  generally  gives  rise  to 
well-marked  symptoms,  which,  if  they  are  not  characteristic, 
always  strongl}-  point  to  the  affected  organ,  and  ultimately  lead 
to  the  detection  of  the  foreign  body  by  the  sound.  There  are, 
however,  instances  in  which  a  calculus  may  exist  in  the  bladder 
for  a  long  time,  and  even  acquire  a  large  bulk,  without  occasion- 

'  Traite  de  I'Affection  Calculeuse,  p.  48~).     Paris,  1838. 

2  Segalas,  Essai  siir  la  Gravelle  et  la  Pierre,  p.  155,  sec.  edit.     Paris,  18:>!». 

3  Amer.  Journ.  ]\Ied.  Sciences,  vol.  xi.,  N.  S.,  p.  492. 

14 


210  STOXE    IX    THE    BLADDEE. 

inor  any  local  suffering  indicative  of  its  formation,  such  as  spas- 
modic pain,  frequent  micturition,  and  sudden  interruption  of  the 
stream  of  urine.'  To  cases  of  this  kind  the  term  latent  may  very 
properly  be  applied. 

Latent  stone  is  most  common  in  advanced  life,  though  it 
occasionally  occurs  at  an  earlier  period.  I  am  not  aware  that  it 
has  ever  been  noticed  in  children  or  young  adults. 

It  is  not  easy  to  account  for  the  absence  of  suffering  in  such 
cases.  Various  circumstances  have  been  adduced  for  the  purpose 
of  explaining  it,  but  very  few  of  them  are,  it  must  be  confessed, 
either  philosophical  or  satisfactory.  The  generally  received 
opinion  is  that  it  is  owing  to  the  smoothness  and  immobility  of 
the  morbid  product,  and  to  the  w^ant  of  sensibility  of  the  mucous 
membrane.  This  view  appears  to  be  confirmed  by  the  interesting 
cases  mentioned  by  Frere  Cosme,^  and  Van  Helmont.  In  the 
former,  that  of  a  watchmaker,  forty-live  years  old,  the  patient 
never  experienced  any  suffering  in  the  bladder,  except  that  he 
could  not  retain  his  water  long.  This  continued  for  many  years, 
when  one  day,  in  lifting  a  heavy  clock,  he  was  suddenly  seized 
witli  a  severe  pain  in  the  hypogastric  region.  This  becoming 
gradually  more  and  more  insupportable,  he  was  induced  to  enter 
one  of  the  public  hospitals  of  Paris,  where  the  sound  detected  a 
large  calculus,  which  was  removed  by  the  high  operation,  and 
which  weighed  twenty-four  ounces.  In  the  case  related  by  Van 
Helmont,  the  patient,  a  priest,  without  any  previous  suffering, 
suddenly  experienced  symptoms  of  stone  from  lifting  a  book. 
The  concretion  was  easily  detected  by  the  sound,  and  was  after- 
wards removed  by  an  operation.  In  each  of  these  instances  the 
calculus  evidently  changed  its  situation,  in  consequence  of  the 
exertion  made  by  the  patient  in  lifting  a  heavy  weight;  it  might 
have  been  encysted,  inclosed  in  a  pouch,  or  attached  by  a  band 
of  false  membrane,  which  gave  way  at  the  moment,  and  thus 
led   to  the  usual  symptoms,  as  well  as  to  the  necessity  for  an 

'  Henricus  ab  Heer  (Observationes  Medicae  rariores,  ob.  26,  1C85)  mentions  an 
instance  in  which  the  stone  attained  the  magnitude  of  a  goose's  egg,  without 
producing  an\'  sj-mptoms.  Mr.  Howship  (A  Practical  Treatise  on  the  Urinary 
Organs,  p.  125,  London,  1823)  states  that  he  examined  the  body  of  a  man 
whose  bladder  contained  at  least  a  dozen  calculi,  several  of  them  as  large  as  a 
chestnut,  and  yet  he  never  had  any  symptoms  of  the  disease. 

2  Deschamps,  Traite  de  la  Taille,  t.  i.  p.  166. 


PHYSICAL    SIGNS,   SOUNDING,   DIAGNOSIS.  211 

Operation.  When  the  concretion  lies  loose  in  the  bladder,  the 
absence  of  symptoms  may  be  accounted  for  by  supposing  that 
tliere  is  great  and  permanent  insensibility  of  the  mucous  mem- 
brane of  tlie  bladder,  such  as  might  be  supposed  to  exist  in 
partial  or  complete  paralysis  of  that  organ.  A  ease,  recorded  by 
Deschamps,^  appears  to  have  l)een  of  this  description.  The 
patient,  an  octogenarian  tailor,  had  frequent  retention  of  urine 
from  palsj^  of  the  bladder  ;  and,  although  a  stone  was  distinctl}' 
felt  by  the  sound,  he  never  experienced  any  of  the  ordinarj- 
phenomena  of  the  malady. 

A  case,  in  which  there  appears  to  have  been  an  absence  of 
local  symptoms,  although  the  bladder  contained  a  large  number 
of  loose,  as  well  as  encysted  calculi,  is  mentioned  in  a  preceding 
section.  It  occurred  in  an  old  man,  a  ])atient  of  Dr.  Johnson, 
of  Richmond,  Virginia,  and  is  one  of  the  most  remarkable 
examples  of  vesical  calculi  on  record. 

We  are  not  sufKciently  familiar  with  the  latent  form  of  vesical 
calculus  to  enable  us  to  judge  what  influence  affections  of  other 
parts  of  the  body  may  have  in  disguising  it,  or  preventing  the 
development  of  local  symptoms.  Further  and  more  faithfully 
conducted  observations  than  any  that  have  yet  been  made  can 
alone  settle  this  question.  For  the  present,  it  is  enough  to  know 
that  such  a  form  of  disease  occasionally  exists. 

One  great  object  in  sounding  is  to  determine,  if  possible^  the 
existence  or  non-existence  of  stone.  Another  object,  hairdly  less 
important,  especially  in  reference  to  the  ultimate  dislodgment 
of  the  foreign  body  by  an  oiDcration,  is  to  ascertain  the- condition 
of  the  urinary  apparatus.  This  can  frequently  be  accomplished 
in  no  other  manner.  By  moving  the  instrument  about  the 
bladder  in  diflerent  directions,  touching  first  one  part  and  then 
another,  and  duly  weighing  the  impressions  which  it  conveys  to 
the  hand,  we  become  apprised  of  the  capacity  of  the  organ,  and 
the  amount  of  its  sensibility  or  tolerance.  Moreover,  we  can 
generally  determine,  with  considerable  accuracy,  by  such  a  mode 
of  exploration,  whether  the  inner  surface  of  the  bladder  is  smooth 
or  rougli,  ulcerated  or  fasciculated,  incrusted  with  lymph  or 
sabulous  matter,  or  the  seat  of  morbid  growths.  The  passage  of 
the  sound  along  the  urethra  enables  us  to  judge  whether  this 

'  Op.  cit.,  t.  i.  p.  16.^. 


212  STOXE    IN    THE    BLADDER. 

canal  is  healthy  or  diseased,  contracted,  changed  in  its  direction, 
or  obstructed  by  the  presence  of  a  foreign  body  or  an  adventitious 
formation.  The  condition  of  the  prostate  gland  is  best  determined 
by  inserting  the  finger  into  the  rectum,  at  the  same  time  that 
the  sound  is  pressed  against  it  from  before  backwards.  We  can 
thus  often  prett}'  accurately  measure  its  dimensions,  its  degree 
of  consistence,  and  the  amount  of  obstruction  which  it  produces 
at  the  neck  of  the  bLidder,  both  as  it  respects  the  emission 
of  the  urine  and  the  passage  of  instruments.  The  anus  and 
rectum  should  also  be  carefully  examined,  either  by  the  finger 
alone,  or  by  means  of  the  speculum,  with  a  view  to  ascertain 
whether  they  are  healthy  or  diseased.  The  light  which  we  derive 
from  these  explorations  frequently  enables  us  to  form  a  tolerably 
correct  idea  of  the  propriety  of  surgical  interference,  or  the 
probable  issue  of  the  case. 

Sect.  YL— PATHOLOGICAL  EFFECTS. 

Although  the  formation  of  vesical  calculus  is  the  immediate 
result  of  a  morbid  condition  of  the  urinary  secretion,  the  blad- 
der and  its  associated  organs  are  generally  diseased,  to  a  greater 
or  less  extent,  in  the  progress  of  the  attection.  The  primary 
impression  is  probably  always  made  upon  the  viscus  in  which 
the  concretion  is  confined  ;  but  the  irritation  which  its  protracted 
presence  there  induces  is  gradually  reflected  upon  the  other 
portions  of  the  apparatus,  awakening  in  them,  in  the  first  in- 
stance, important  sympathetic  actions,  and  ultimately  serious 
structural  lesions.  The  secondary  efi:ects  thus  set  up  are  some- 
times suflicient  to  mask  the  original  disease,  and  often  lay  tlie 
foundation  for  the  jtatient's  destruction,  long  before  it  would 
otherwise  take  place. 

One  of  the  first,  and  indeed  almost  necessary  efiects,to  which 
the  foreign  body  gives  rise,  is  infiammatiou  of  the  mucous  coat 
of  the  bladder,  which  is  most  severe  at  the  neck  and  bas-fond, 
and  is  followed  not  infrequently  by  thickening,  increased  vascu- 
larity, and  the  development  of  j)apill8e  or  ulceration.  The  irri- 
tation, at  first  limited  to  the  mucous  membrane,  gradually 
extends  to  the  other  tunics  which  become  hypertropliied,and  in 
the  advanced  stages  of  the  disease,  are  often  accompanied  by  a 
fasciculated  and  sacculated  state  of  the  bladder.     A  copious 


PATHOLOGICAL    EFFECTS.  213 

secretion  of  thick,  tough  mucus,  usually  attends  these  morbid 
clianges,  and,  not  infrequently,  even  a  considerable  discharge 
of  pus,  lymph,  or  blood,  or  of  all  these  substances  together. 

A  diminution  in  the  size  of  the  bladder  is  not  uncommon,  even 
in  young  subjects,  but  is  much  more  frequent  in  old  persons  wko 
have  labored  for  many  years  under  the  continued  irritation  of  a 
calculus.  It  is  almost  alwaj's  a  concomitant  of  the  hypertrophied 
and  fasciculated  condition,  and  may  go  on  until  the  organ  is 
unable  to  contain  more  than  an  ounce  or  two  of  urine.  The 
opposite  of  this  state,  or  an  increase  of  size,  is  occasionally  met 
with.  It  occurs  chieHy  in  ver}- old  subjects,  and  in  persons  who 
liave  long  suffered  under  paralysis  of  the  bladder.  It  varies  in 
extent  from  the  slightest  increase  to  double  and  even  triple  the 
natural  volume. 

One  of  the  most  distressing  accidents  wliicli  take  place,  during 
the  progress  of  this  disease,  is  perforation  of  the  bladder,  fol- 
lowed by  a  partial  or  complete  escape  of  the  stone,  and  the 
formation  of  a  fistule.  When  it  is  accompanied  by  extravasation 
of  urine  into  the  surrounding  connective  tissue,  it  may  terminate 
fatally  in  a  few  days,  or  lead  to  violent  inflammation  and  sup- 
puration, inducing  death  at  a  more  distant  period.  The  part  of 
the  bladder  most  prone  to  perforation  is  the  bas-fond ;  but  the 
opening  may  take  place  at  any  point.  Thus,  a  calculus  has  been 
known  to  escape  at  the  groin,  above  the  pubes,  and  at  the  peri- 
neum. In  the  female,  it  may  be  discharged  through  the  vagina, 
and  tbus  occasion  a  vesico- vaginal  list ule. 

The  urethra  rarely  suffers,  except  in  its  prostatic  portion, 
which  may  be  unnaturally  red,  inflamed,  hypertrophied,  or 
attenuated.  When  the  calculus  is  small,  and  is  often  forcibly 
impelled  into  the  canal  by  the  stream  of  urine,  it  may  become 
greatly  dilated,  and  even  transformed  into  a  pouch. 

A  calculus  seldom  remains  long  in  the  bladder  without  excit- 
ing disease  in  tlie  prostate  gland.  This  frequently  happens,  even 
in  ver\'  3'oung  subjects,  and  while  the  malady  is  still  in  its  incipi- 
ency  ;  but  is  much  more  conmion  in  the  aged  and  in  the  more 
advanced  periods.  The  organ,  from  the  continued  irritation 
which  it  suffers,  receives  an  unnatural  amount  of  blood,  in  con- 
sequence of  which  it  gradually  increases  in  volume  and  density, 
and  thereby  immensely  aggravates  the  primary  affection.  It 
sometimes  enlarges   in  every  direction,  impeding  the  flow  of 


214  STONE    IN    THE    BLADDER. 

urine,  augmenting  the  pain  and  spasm  of  the  bladder,  and  even 
producing  serious  pressure  upon  the  rectum.  Ulceration,  abscess, 
and  sloughing  may  follow  from  the  constant  and  excessive  irri- 
tation. In  some  instances,  the  prostate  is  converted  into  a 
cavity,  nearly  equal  to  that  of  the  contracted  bladder  itself,  and 
capable  of  lodging  a  calculus  of  considerable  size.  On  the  other 
hand,  the  gland  may  be  greatly  diminished  in  volume. 

The  ureters  are  frequently  inflamed  and  thickened,  and  some- 
times even  ulcerated.  One  or  both  are  occasionally  enormously 
enlarged,  or  one  is  enlarged  and  the  other  contracted.  'J'hese 
changes  are  most  common  in  old  subjects,  and  in  protracted  cases. 

The  kidneys  rarely  entirely  escape  in  this  disease.  There  are 
few  cases,  of  long  standing,  in  which  they  are  not  inflamed, 
increased  in  size,  or  altered  in  structure.  In  the  worst  forms  of 
the  malady,  it  is  not  unusual  to  see  one  of  them  converted  into 
a  large  i:)0uch  filled  with  purulent  matter,  or  turbid  urine.  In 
rare  cases  Bright 's  disease  is  present. 

Abscesses  and  fistules  occasionally  form  in  the  perineum  ;  and, 
from  the  frequent  straining  to  which  the  patient  is  subjected  in 
micturition,  prolapse  of  the  anus  takes  place,  attended  with  re- 
laxation of  the  sphincter  muscle,  inflammation  and  thickening 
of  the  mucous  membrane,  and  hemorrhoidal  tumors. 

The  orifices  of  the  seminal  ducts  are,  in  many  cases,  dilated, 
or  otherwise  affected,  and  the  ductsthemselvesmay  be  variously 
altered.  The  seminal  vesicles  are  sometimes  atrophied,  or  dimi- 
nished in  volume,  and  changed  in  structure.  Wiien  the  neck 
or  bas-fond  of  the  bladder  suft'ers  much,  one  or  both  of  these 
reservoirs  may  become  acutely  inflamed,  and  sometimes  even 
gangrenous. 

A  calculus  of  the  bladder  has  sometimes  obstructed  parturi- 
tion, and  required  extraction  before  the  labor  could  be  completed. 
Such  a  case  occurred  in  the  practice  of  Dr.  Monod,^  in  a  woman 
of  forty,  pregnant  for  the  first  time.  In  a  similar  case,  related 
by  Mr.  Thralfall,^  of  Liverpool,  both  mother  and  child  were  per- 
mitted to  perish,  in  consequence  of  the  nature  of  the  obstruction 
not  being  detected  until  after  death. 

Finally,  another  effect,  which  has  occurred  in  at  least  thirty- 

'  New  York  Joiini.  of  Med.  and  Surg.,  p.  27-1,  Sept.  1850. 
2  Loudon  iled.  and  Surg.  Jouru.,  vol.  ii.  p.  180,  1829. 


PROGNOSIS    OF    VESICAL    CALCULUS.  215 

six  instances,'  is  the  spontaneous  fracture  of  the  calculus,  suc- 
ceeded by  violent  irritation  of  the  bladder,  and  sometimes  even 
by  the  death  of  the  patient.  The  sharp,  angular,  and  rugged 
points  of  the  fragments  fret  and  irritate  the  mucous  membrane, 
which  is  thus  induced  to  take  on  inflammation,  which  is  some- 
times so  intense  and  so  unmanageable  as  to  destroy  life  in  a  few 
days.  Besides,  some  of  the  pieces  may  lodge  in  the  urethra,  and 
produce  partial  or  complete  retention  of  urine. 

The  immediate  cause  of  fracture  of  urinary  calculi  within  the 
bladder  is  no  doubt  the  inordinate  contraction  of  the  muscular 
fibres  of  this  organ.  It  may  also  be  produced  by  the  stones, 
especially  if  they  be  numerous,  striking  violently  against  each 
other  during  severe  bodily  exercise,  as  in  leaping  and  running, 
and  riding ;  and  it  has  been  known  to  follow  sounding.  In 
other  cases,  again,  as  in  those  recorded  by  Mr.  Southam,^  the 
accident  was  evidently  due  to  the  generation  of  gas  within  the 
calculus  itself,  from  the  decomposition  of  its  mucous  cementing 
material. 

Sect.  YII.— PPtOGNOSIS  OF  VESICAL  CALCULUS. 

.  A  small  stone  is  sometimes  passed  spontaneously,  especially  in 
the  female,  owing  to  the  shortness  and  dilatability  of  the  ure- 
thra in  that  sex.  Cases  have  occurred  in  which  riddance  was 
effected  by  ulceration  of  the  bladder,  the  concretion  escaping  at 
the  groin,  the  hjqijogastrium,  the  perineum,  the  rectum,  or  the 
vagina.  Such  a  termination  is  attended  with  severe  local  suffer- 
ing, and  constitutional  disturbance.  As  a  rule,  the  prognosis  is 
favorable  if  the  calculus  be  discovered  at  an  early  period,  and 
steps  are  taken  to  get  rid  of  it.  If  it  is  permitted  to  remain,  it 
generally  steadily  increases  in  volume,  and  ultimately  leads  to 
serious  organic  disease  of  the  prostate,  bladder,  ureters,  and 
kidneys,  which  causes  not  only  a  great  deal  of  suffering,  but 
literally  wears  out  the  life  of  the  patient. 

Spontaneous  fracture  of  a  calculus  is  always  attended  with 
danger,  although,  in  exceptional  instances,  a  sort  of  natural  cure 
may  result  through  the  discharge  of  the  fragments  by  the  ure- 

'  Otto  Schmidt,  Beitnige  zur  Chirurgischeu  Pathologie  der  Handwerkzeuge, 
Leipzig,  1865,  pp.  1-31. 

2  George  k^^outliain,  British  Medical  Journal,  vol.  i.  18G8,  p.  3. 


216  STOXE    IX    THE    BLADDER. 

thra.  So  fortunate  an  issue  is  not,  however,  to  be  anticipated; 
hence,  no  time  should  be  lost  in  resorting  to  lithotomy.  Even 
under  these  circumstances,  the  prognosis  is  not  quite  so  good  as 
when  the  ordinary-  operation  is  performed,  since  of  eleven  re- 
corded cases  of  lithotomy  for  fractured  calculus,  two  perished. 


CHAPTER  IX. 

TREATMENT  OF  STONE  IN  THE  BLADDER. 

The  treatment  of  stone  in  tlie  Madder  necessarily  divides  itself 
into  medical  and  surgical,  of  which  the  former  is,  in  general, 
merely  palliative,  although  frequently  of  paramount  importance, 
whether  it  be  considered  only  with  reference  to  the  temporary 
comfort  of  the  sutterer,  or  as  a  means  of  improving  his  health 
with  a  view  to  his  relief  by  an  operation.  Each  of  these  subjects 
should  be  well  understood,  and  it  will,  therefore,  be  proper  to 
discuss  them  somewhat  at  length. 

Sect.  I.— MEDICAL  TREATMENT. 

Persons  affected  with  stone  in  the  bladder  do  not  always  find 
it  convenient  to  submit  to  an  operation,  and  it  therefore  be- 
comes a  matter  of  great  importance  to  render  them  as  comfort- 
able as  their  circumstances  may  admit  of.  By  attention  to 
the  general  health,  as  regulated  by  food,  drink,  and  exercise, 
much  may  be  done  to  allay  local  suffering,  and  make  the  patient 
almost  forget  his  disease.  A  concretion,  Avhich  may  have  been 
a  source  of  great  distress  for  years,  may,  by  appropriate  and 
well-directed  treatment,  become  a  comparatively  harmless  tenant 
of  the  bladder,  and  thus  a  state  of  torture  be  converted  into  one 
of  Elysium.  Many  cases  are  on  record,  in  Avhich,  from  the  im- 
provement of  their  symptoms,  calculous  subjects  have  imagined 
themselves  cured  of  their  ailments,  when,  in  fact,  the  change 
they  experienced  was  solely  owing  to  the  increased  tolerance  of 
the  organ,  in  consequence  of  the  effects  of  remedies.  The  im- 
provement thus  produced  has  sometimes  lasted  many  years, 
although,  in  general,  it  is  comparatively  short.  A  consideration 
of  this  circumstance  has  led  to  a  belief,  not  altogether  unfounded, 
that  urinary  concretions  are  sometimes  dissolved  in  the  bladder, 
and  voided  along  with  the  urine.  Hence,  certain  remedies, 
supposed  to  be  endowed  with  this  property,  have  received  the 
name  of  lithontriptics,  or  solvents  and  disintegrators  of  stone. 


218  TREATMENT    OF    STONE    IX    THE    BLADDER. 

It  is  hardly  necetisary  to  remark  that  a  due  regulation  of  tlie 
diet  is  of  paramount  importance  in  the  treatment  of  stone  in  the 
bladder.  Most  patients,  in  fact,  know  from  painful  experience, 
the  kind  of  food  and  drink  that  agrees  best  with  the  stomach. 
In  adults,  therefore,  little  caution  in  this  respect  is  necessary ; 
but  in  children,  who  are  unable  to  judge  for  themselves,  the 
proper  injunctions  should  always  be  given  to  the  parents  and 
nurses.  Without  entering  into  details,  which  the  limits  of  this 
treatise  forbid,  it  may  be  observed,  in  general  terms,  that  the 
diet  should  be  plain  and  simple,  easy  of  digestion,  and  yet  suffi- 
ciently nutritious.  Plainly  roasted  meats,  oysters,  boiled  iish, 
mealy  Irish  and  dr}'  sweet  potatoes,  well-boiled  rice  and  hominy, 
soda  biscuit,  and  stale  wheat  bread,  with  weak-tea,  or  milk  and 
water,  are,  in  general,  the  most  suitable  articles.  Coffee,  wine,  and 
fermented  liquors,  cider,  and  subacid  fruits,  with  pastry,  and  the 
coarser  kinds  of  A^egetables,  are  to  be  eschewed.  If  the  patient 
be  feeble,  or  has  been  in  the  habit  of  using  liquor,  a  little  brandy, 
or,  what  is  better,  gin,  may  be  allowed  at  dimier,  and  after  exer- 
cise. Gin,  as  is  well  known,  has  a  sort  of  specific  tendency  to 
the  urinary  organs,  and  its  exhibition  is  occasionally  attended 
with  good  effects.  Some  persons  are  greatly  benefited  by  hop- 
tea,  beer,  or  malt  liquors.  Generallj'  speaking,  however,  these 
articles  produce  more  harm  than  good.  All  kinds  of  water 
impregnated  with  lime  must  be  abstained  from,  from  their 
tendency  to  favor  the  increase  of  calculous  deposits.  The  patient 
should  be  well  clad,  avoid  exposure  to  wet  and  cold,  and  refrain 
from  rough  exercise  of  every  description.  In  the  winter,  he 
should  keep  himself  well  housed,  or  reside,  if  possible,  in  a  warm 
and  genial  climate.  Sexual  excitement  must  be  carefully  guarded 
against,  for  any  indulgence  of  the  kind  is  always  sure  to  be  fol- 
lowed by  an  aggravation  of  the  complaint. 

The  urine  must,  in  all  cases,  be  kept  in  as  neutral  and  diluted 
a  condition  as  possible.  AVhen  it  throws  down  a  co}»ious  de[)Osit 
of  urates,  uric  acid,  or  oxalate  of  lime,  the  patient  should  drink 
an  abundance  of  water,  as  it  is  well  known  that  these  sediments 
rarely  occur  in  excess  when  the  fluids  of  the  body  are  maintained 
in  a  state  of  dilution.  If  it  be  acid,  alkalines  are  indicated  ;  if 
alkaline,  acids  are  required,  Frequent  examinations  of  this 
fluid  are,  therefore,  necessary-,  in  order  that  the  remedies  may 
be  varied  as   the   circumstances  of  each  particular  case  may 


MEDICAL    TREATMENT.  219 

render  it  proper.  It  should  be  remarked  here  that  some  patients 
ire  most  benefited  by  alkalies,  others  by  acids,  even  when  the 
irine  and  the  stone  are  both  apparently  of  the  same  character. 
^o  satisfactory  reason  can  be  offered  for  this  seeming  discrepancy, 
rt^ith  which  every  physician  of  experience  is  familiar.  In  my 
3vvn  practice,  I  have  generally  derived  most  benefit  from  the 
ase  of  alkaline  remedies,  whatever  may  have  been  the  nature  of 
the  diathesis  or  concretion. 

The  best  alkalies  in  the  treatment  of  vesical  calculi  are,  be- 
yond all  question,  the  bicarbonates  of  soda  and  potassa,  either 
ilone,  or  variously  combined  with  each  other.  In  my  own 
practice,  I  have  generally  given  a  preference  to  the  soda,  for  the 
reason  that  it  has  seemed  to  me  to  exert  a  more  obtunding  etlect 
upon  the  mucous  surfaces  of  the  urinary  passages.  The  best 
form  of  exhibition  is  in  solution  in  strong  hop  and  uva  ursi  tea, 
in  tlie  proportion  of  thirty  grains  to  an  ounce,  three  or  four 
times  a  day.  The  best  period  for  using  the  medicine  is  about 
one  hour  after  meals  and  at  bedtime.  Exhibited  in  this  w\ay, 
it  readily  mixes  with  the  ingesta,  prevents  the  evolution  of 
acidity  and  flatulence,  and  exerts  a  more  controlling  influence 
over  the  urinary  secretion.  The  quantity  of  the  salt  may  be 
gradually  increased  to  forty,  fifty,  and  even  sixty  grains,  ac- 
cording to  the  tolerance  of  the  stomach  ;  and  a  good  plan  is  to 
pretermit  the  use  of  it  occasionally  for  a  few  days.  Carbonate 
of  potassa  is  sometimes  employed  alone,  but  its  beneficial  influ- 
ence is  always  greatly  enhanced  by  giving  it  in  union  wdth  soda. 
The  liquor  potass;©  sometimes  answers  an  excellent  purpose  in 
these  cases,  particularly  in  persons  of  a  dyspeptic  habit.  It 
should  be  administered  largely  diluted  with  water,  in  doses 
varying  from  twenty  to  forty  drops,  three  times  daily,  or,  what 
is  better  under  such  circumstances,  in  combination  with  some 
of  the  simple  bitters,  as  tincture  of  gentian,  quassia,  or  cinchona. 
Some  patients  derive  much  benefit  from  the  free  use  of  lime- 
water,  Castile  soap,  magnesia,  and  lye.  The  celebrated  remedy 
of  Mrs.  Stephens,  purchased  more  than  a  century  ago,  at  an 
enormous  expense,  by  the  English  government,  consisted  of 
Castile  soap  and  egg-shells.  Daring  the  height  of  its  renown, 
and  before  its  composition  was  disclosed,  it  was  the  fashionable 
medicine  with  calculous  patients,  of  everj^  condition  and  rank, 
in  Great  Britain ;  it  was  swallowed   in   large  quantities,  and 


220      TREATMENT  OF  STONE  IX  THE  BLADDER. 

there  is  reason  to  believe  that  it  often  produced  the  most  salu- 
tary effects. 

Marked  benefit,  sometimes  of  a  jiermanent  character,  arises 
from  the  long-continued  use  of  certain  mineral  waters.  Of  the 
various  waters  celebrated  for  their  virtues  of  solving  calculi  and 
soothing  the  bladder,  those  of  Vichy,  in  France,  are  the  most 
remarkable,  on  account  of  the  numerous  cases  that  have  been 
relieved  by  their  use.  Their  reputation  extends  back  several 
centuries,  and  their  efficacy  has  been  corroborated  by  the  testi- 
mony of  some  of  the  most  respectable  physicians  of  modern  times. 
The  Vichy  waters  contain  a  large  quantity  of  free  carbonic  acid, 
and  very  nearl}'  a  drachm  and  a  half  of  bicarbonate  of  soda  in 
every  thousand  drachms  of  the  menstruum,  upon  the  presence  of 
which  their  good  effects  no  doubt  depend.  'J'he  probability  is 
that  these  and  similar  waters  act  not  as  mere  diluents,  but  that 
they  also  exert  some  chemical  influence  upon  the  urine.  Whether 
any  of  the  mineral  waters  found  in  such  immense  numbers  and 
varieties  in  this  country,  possess  virtues  similar  to  those  of  the 
Vichy  waters  as  stone  solvents,  experience  has  not  determined. 
It  is  certain,  however,  that  many  calculous  patients  have  de- 
rived much  benefit  from  their  use. 

When  the  urine  is  decidedly  alkaline  in  its  character,  acids 
are  indicated,  and  it  is  remarkable  how  soon,  in  many  cases,  under 
these  circumstances,  their  good  effects  become  manifest,  since 
they  seldom  fail  to  improve  the  condition  of  the  digestive  appa- 
ratus, to  allay  flatulence,  and  to  promote  the  appetite,  and,  just 
in  proportion  as  they  do  this,  do  tliey  improve  the  state  of  the 
urinary  organs.  The  length  of  time  during  which  they  should 
l)e  continued  must  depend  upon  circumstances.  I  have  found 
in  my  OAvn  practice  that  the  alternate  use  of  acids  and  alkalies 
is  generallj'  productive  of  more  benefit  in  the  treatment  of  calcu- 
lous complaints  than  the  protracted  use  of  either  of  these  sub- 
stances alone. 

The  acids  which  are  usually  employed  to  produce  these 
changes  are  the  nitric,  hydrochloric,  and  benzoic,  of  which  the 
former  is  the  preferable.  The  best  form  of  exhibition  is  the 
dilute  nitric  acid  of  the  shops,  in  doses  of  from  twent}'  to  thirty 
drops,  three  times  daily,  in  nearly  half  a  tumblerful  of  cold 
water,  sweetened  with  a  little  sugar,  to  render  it  palatable.  The 
sulphuric  acid  is  also  sometimes  used,  but  its  good  effects  are 


LITHOLYSIS.  221 

less  apparent,  and  occasionally  it  seems  to  be  rather  prejndicial 
than  beneficial.  Much  improvement  sometimes  results  from  the 
exliibition  of  phosphoric  acid  ;  and  cases  occur  in  which  marked 
relief  follows  from  the  use  of  certain  vegetable  acids,  as  the  citric 
and  tartaric. 

Sect.  IL— LITHOLYSIS. 

The  idea  of  dissolving  stone  in  the  bladder  by  means  of  injec- 
tions is  not  new ;  but  past  experience  and  modern  experiments 
conclusively  show  that  }.)hosphatic  calculi  are  alone  amenable  to 
this  form  of  treatment.  Of  the  ditterent  remedies  that  have 
been  reconmiended,  the  only  ones  entitled  to  confidence  are 
the  dilute  nitric  acid,  and  acetate  of  lead,  in  the  proportion  of 
about  two  drachms  of  the  former,  and  sixteen  grains  of  the  latter, 
to  the  pint  of  water.  Sir  Benjamin  Brodie,'  as  is  well  known, 
succeeded  in  dissolving  two  phosphatic  stones  by  passing  a  solu- 
tion of  nitric  acid  slowly  and  steadily  oyer  them  by  means  of  a 
double  catheter,  for  fifteen  to  thirty  minutes  every  two  or  three 
days.  ]More  recently,  Mr.  Southam^  tried  the  same  method, 
with  equal  success,  in  a  case  of  the  repeated  formation  of  fresh 
concretions  after  crushing  a  phosphatic  calculus.  In  the  course 
of  a  short  time  the  old  fragments  were  completely  dissolved  and 
the  formation  of  new  ones  was  prevented.  This  treatment  is 
worthy  of  still  further  trial  as  an  aid  to  lithotrity. 

Some  3"ears  ago  Dr.  Hoskins^  suggested  the  emploj'ment  of 
nitrosaccharate  of  lead  as  a  perfectly  unirritating  agent  to  dis- 
solve phosphatic  concretions,  for  which  he  afterwards  substituted 
acetate  of  lead,  with  the  addition  of  the  merest  trace  of  acetic 
acid,  to  secure  solution  of  the  salt.  The  idea  is  very  ingenious, 
as  a  double  decomposition  ensues,  which  results  in  the  formation 
of  phos[>hate  of  lead  and  acetate  of  lead  and  magnesia,  which 
are  harmless  to  the  mucous  membrane  of  the  bladder.  The  fluid 
may  he  allowed  to  remain  in  the  viscus  as  long  as  it  can  be  re- 
tained, or  a  slow  current  may  be  maintained  through  the  bladder 
by  means  of  a  double  catheter,  connected  hy  a  gum  tulic  to  a 
reservoir  elevated  above  the  level  of  the  bed. 

I  have  no  experience  with  this  mode  of  treating  stone,  and  I 

'  Op.  cit.,  pp.  300-311. 

2  Dr.  Roberts,  Med.  Chir.  Trans.,  vol.  xlviii.  p.  133. 

'  Lond.  Journ.  Med.,  vol.  iii.  p.  891. 


222      TREATMENT  OF  STONE  IX  THE  BLADDEE. 

supj)ose  few  surgeons  in  this  country  have.  Most  of  our  calcu- 
lous patients  are  from  a  distance,  and  are  anxious,  when  they 
reach  us,  to  be  relieved  as  speedily  as  possible  of  their  burden. 
Few  have  the  time,  or  means,  or  patience,  to  submit  to  a  process, 
which,  while  it  must  always  be  tedious  and  inconvenient,  is 
generally  uncertain,  sometimes  painful,  and  not  always  devoid 
of  danger.  The  subject,  however,  is  worthy  of  further  attention, 
and  it  is  to  be  hoped  that  it  will  be  investigated  in  a  manner 
commensurate  with  its  imjiortance. 

Electrolysis  has  been  applied  to  the  solution  of  urinary  calculi. 
This  agent  was  first  suggested,  for  purposes  of  this  kind,  by 
Bouvier  Desmortiers,  who  actually  performed  some  experiments 
with  it,  though  the  effects  which  he  obtained  were  very  tardy 
and  unsatisfactory.  The  subject  w^as  afterwards  taken  up  by 
Gruithuisen,  Prevost  and  Dumas,  Bonnet,  Willis,  O'Shaugnessy, 
Bence  Jones,  and  other  practitioners,  with  hardly  any  better 
success.  Dr.  Ludwig  Melicher^  is  said  to  have  been  successful 
in  two  cases  ;  but  I  am  not  aware  of  a  single  w'ell-authenticated 
instance  of  disintegration  of  a  calculus  hy  the  application  of  this 
agent.  My  own  opinion  is  that  little  is  to  be  expected  from  it, 
and  that  it  would  l)c  a  mere  waste  of  time  to  resort  to  it. 

Sect.  III.— EXTRACTION  OF  CALCULI  THROUGH  THE  URETHRA. 

Tbe  fact  that  small  calculi  sometimes  escape  during  micturi- 
tion was  long  ago  noticed  by  practitioners,  and  has  been  turned 
to  good  account  by  modern  surgeons.  When  it  is  known,  for 
example,  that  a  concretion  has  recently  descended  from  the  kid- 
ney, its  expulsion  from  the  bladder  may  occasionally  be  effected 
by  making  the  patient  grasp  the  head  of  his  penis,  while  he 
distends  the  urethra  with  urine  ;  then,  letting  go  his  hold,  he 
empties  his  bladder  with  all  the  force  lie  can  direct  upon  it  by 
the  action  of  the  diaphragm  and  abdominal  muscles.  The  water 
should  be  previously  accumulated  to  the  greatest  possible  extent, 
and  during  its  evacuation  the  patient  should  lie  upon  his  belly, 
or  bend  his  body  forward,  to  place  the  stone  in  the  most  favor- 
able position  for  reaching  the  urethra.  These  attempts  at 
extrusion  are  generally  much  facilitated  by  the  prior  dilatation 
of  the  canal  by  means  of  the  bougie  or  catheter.     The  urethra, 

'  Beale,  Kidney  Diseases,  etc.,  3d  ed.,  p.  430. 


EXTRACTIOX    OF    CALCULI    THROUGH    THE    URETHRA.      223 


Fiff.  56. 


being"  thus  expanded  to  a  greater  or  less  extent,  will  more  readily 
admit  the  passage  of  the  foreign  body  by  the  pressure  of  the 
advancing  stream  of  water.  When  the  concretion  is  quite 
small,  a  single  introduction  of  the  instrument  will  sometimes 
suffice;  but,  in  general,  systematic  dilatation  will  be  necessary, 
and  this,  it  need  hardly  be  added,  should  always  be  conducted 
with  the  greatest  care  and  gentleness. 

Attempts  have  been  made,  especially  in  recent  times,  to  remove 
calculi  entire  from  the  bladder,  through  the  urethra,  by  means 
of  forceps.  It  was  observed,  long  ago,  that  during  catheterism, 
small  concretions  became  occasionally  impacted  in  the  eyelets  of 
the  instrument,  which  they  followed  upon  its  withdrawal.  A 
circumstance,  so  interesting  and  important,  was  well  calculated 
to  arrest  the  attention  of  surgeons,  and  we  accordingly  find  that 
they  have  taken  full  advantage  of  it.  It  was  in  this  way  that 
the  late  Mr.  George  Bell,  of  Edinburgh,  had  the  good  fortune  to 
rid  a  patient  of  one  hundred  and  fifty  concre- 
tions. In  performing  such  an  operation,  a  full- 
sized  catheter  with  two  large  eyes  should  be 
selected,  and  the  bladder  should  be  previously 
distended  with  water,  so  that,  as  the  fluid  runs 
off",  the  calculi  may  have  a  better  chance  of 
being  forced  into  the  tube. 

Instruments  have  been  constructed  for  the 
special  purpose  of  seizing  the  stone,  and  re- 
moving it  entire.  Sanctorius,  if  not  the  first, 
was  one  of  the  earliest  surgeons  who  busied 
themselves  in  this  manner.  He  has  described 
the  operation  with  some  minuteness,  and  has 
figured  a  pair  of  forceps  which  he  contrived  for 
performing  it.  Hales,  Hunter,  and  others  also 
invented  instruments,  which  have  been  greatly 
improved  in  modern  times  by  Sir  Astley  Cooper, 
and  some  of  the  French  lithotomists.  The  for- 
ceps of  the  English  surgeon,  which  are  repre- 
sented in  fig.  56,  and  with  which  he  extracted 
upwards  of  eighty  small  calculi  from  one  indi- 
vidual, consist  of  two  movable  blades,  shaped,  when  closed,  like 
a  curved  catheter.  They  are  introduced  in  the  ordinary  manner, 
and  are  used,  at  first,  as  a  searcher.     AVhen  the  stone  is  found, 


Cooper's  Forceps. 


224      TREATMENT  OF  STOXE  IX  THE  BLADDER. 

the  blades  are  gently  separated  and  expanded  over  it,  when, 
being  again  sliut,  the  instrument  is  carefully  withdrawn.  An 
index  upon  the  surface  of  the  instrument  serves  to  show  the  size 
of  the  calculus,  or,  what  is  the  same  thing,  the  possibility  of 
removing  it  entire.  When  the  concretion  cannot  be  extracted 
in  this  manner,  it  may,  if  not  too  hard  or  large,  be  crushed,  and 
be  disposed  of  piecemeal. 

In  performing  this  operation,  it  is  important  that  the  bladder 
should  be  perfectly  free  from  irritation,  that  the  urethra  be 
previously  dilated  by  the  catheter  or  bougie,  and  that  the  forceps 
do  not  pinch  the  mucous  membrane.  If  these  precautions  are 
neglected,  serious  mischief  may  follow.  At  least  one  instance 
is  on  record  where  death  ensued,  although  the  operation  was 
performed  by  a  competent  surgeon,  and  the  forceps  were  intro- 
duced only  twice,^ 

The  removal  of  calculi  by  forceps  is,  for  ol)vious  reasons, 
jDeculiarly  applicable  to  females.  By  rapidly  dilating  the  ure- 
thra, concretions  upwards  of  an  inch  in  diameter  may  be  ex- 
tracted, without  any  subsequent  incontinence  of  urine. 

A  small  calculus  has  sometimes  been  entrapped  and  removed 
by  a  very  simple  procedure.  Many  years  ago,  Dr.  Calvin  Conant^ 
relieved  a  lad,  aged  fifteen,  by  means  of  a  silver  wire,  passed 
through  a  catheter,  the  vesical  extremity  of  which  was  pierced 
by  two  holes,  about  a  line  and  a  half  apart.  The  wire,  which 
was  very  fine,  elastic,  and  twenty  inches  long,  was  formed,  upon 
its  arrival  in  the  bladder,  into  a  loop,  which  was  then  moved 
about  until  the  concretion  was  found  and  ensnared ;  the  ends 
were  next  secured  to  the  shoulders  of  the  catheter,  when  both 
the  instrument  and  stone  were  withdrawn. 

Sect.  IV.— LITHOTRITY. 

It  is  not  my  intention,  in  this  place,  to  enter  into  a  history  of 
lithotrity.  It  may  suffice  to  state  that  it  is  really  an  Italian 
procedure,  Santorio,  in  1626,  and  Ciucci,  in  1670,  having  devised 
instruments,  similar  to  the  trilabe  of  Civiale,  with  which  they 
executed  it.  It  appears,  however,  to  have  been  lost  sight  of 
until  1814,  when  Gruithuisen,  of  Munich,  proposed  to  reduce  a 

'  Brit,  and  Foreign  Med.  Review,  vol.  xii.  p.  404 

2  Medical  Repository,  N.  Series,  vol.  iv.  p.  184.     New  York,  1818. 


LITHOTRITY. 


225 


Fiff.  57. 


stone  to  powder  by  drilling.  Elderton,  of  Scotland,  six  years 
subsequenth'^,  devised  a  curved  litliotrite  for  the  same  purpose. 
From  1817  to  1824,  Civiale  was  engaged  in  perfecting  the  tri- 
labe  and  in  conducting  experiments,  which  culminated,  in  the 
latter  year,  in  the  successful  performance  of  crushing  a  stone  in 
the  human  bladder  before  a  committee  of  tlie  Fre*icli  Academy. 
To  him  is  due  the  credit  of  having  established 
tlie  operation  on  a  firm  footing,  and  brought  it 
to  its  present  degree  of  perfection.  Although 
it  is  certain  that  he  obtained  some  hints  respect- 
ing it  from  previous  and  contemporary  experi- 
menters, yet  it  must  be  evident  to  every  impar- 
tial inquirer  that  the  invention  was  the  result 
mainly  of  his  own  labors  and  ingenuity. 

The  original  instruments  of  Civiale  and  Ja- 
cobson  have  been  replaced,  chiefly  through  the 
suggestions  of  Weiss,  Ileurteloup,  Costello, 
Hodgson,  and  Charriere,  by  the  curved  screw 
litliotrite,  of  which  an  excellent  form,  repre- 
sented in  fig.  57,  leaves  nothing  to  be  desired. 
It  is  from  twelve  to  fourteen  inches  long,  and 
its  shafts  terminate,  at  one  extremity,  in  the 
beak,  which  is  composed  of  the  male  and  female 
blade,  and  at  the  other,  in  a  fluted  cylindrical 
handle  and  a  screw,  turned  by  a  wheel,  which 
can  be  fixed  or  disconnected  by  sliding  the  but- 
ton on  the  handle.  The  femafe  shaft  is  grooved 
to  receive  the  male  shaft,  which  is  provided 
with  a  scale  for  determining  the  volume  of  the 
stone. 

Another  form  of  power,  which  is  useful  when 
the  stone  will  only  yield  to  short  and  quick  per- 
cussions, is  that  by  the  rack  and  pinion,  repre- 
sented in  fig.  58,  and  invented  by  Sir  William 
Fergusson.  The  modification  of  this  instrument  by  Mr. 
Matthews,  in  which  the  shaft  is  very  narrow  and  the  beak  bul- 
lions, is  a  great  improvement  on  the  original  pattern,  as  it  per- 
mits of  greater  delicacy  of  touch  and  freedom  of  play  in  the 
bladder. 

The  operator  should  be  provided  with  at  least  three  instru- 
15 


Weiss"s   and    Thomp, 
son's  Litliotrite. 


226 


TREATMENT  OF  STONE  IX  THE  BLADDER. 


meiits ;  one  with  the  female  blade  open,  as  represented  in  fig.  59, 
and  the  male  blade  dentieulated,  for  breaking  large  and  hard 


U=sJi=^==iU— J 


Fi?.  58. 


Fergussou's  Rack  and  Pinion  Litholrite. 


stones  into  fragments;  one  Avith  flat  and  roughened  blades,  of 
which  tlie  male  is  narrower  than  the  female,  fig.  60,  for  crushing 
calculi  not  above  one  inch  in  diameter,  unless  they  are  very  friable; 
and  a  third  with  roughened  blades  of  nearly  equal  width,  fig.  61, 


Fis.  60. 


Fis:.  61. 


Different  Forms  of  Lithotrile  Blades. 

for  pulverizing  fragments  and  small  stones.  The  angle  formed 
by  the  beak  and  the  shaft  need  not  exceed  105°  or  110°  ;  while 
the  diameter  of  the  shaft  of  the  most  powerful  lithotrite  may 
equal  10  of  the  English  catheter  scale,  and  that  of  the  two  dimen- 
sions of  the  beak  should  measure  13.  For  small  or  friable  con- 
cretions the  respective  diameters  may  equal  7  and  10. 

The  operator  should  also  be  provided  with  Fergusson's  deli- 
cate scoops,  and  Clover's  or  DitteFs  evacuating  apparatus,  for 
the  removal  of  fragments ;  a  gum  bottle  and  catheter  for  inject- 
ing the  bladder;  and  forceps,  curettes,  and  lithoclasts,  for  the 
extraction  of  fragments  impacted  in  the  urethra. 

Before  subjecting  a  patient  to  lithotrity,  the  conditions  which 
favor,  and  those  which  oppose,  the  operation  must  be  carefully 
weighed,  since,  under  favorable  circumstances,  it  is  an  eminently 
successful  procedure  in  skilled  hands,  while,  if  it  be  resorted 
to  indiscriminately,  the  loss  of  life  will  be  far  greater  than  after 
a  cutting  operation.     It  may  be  asserted  that  irapubic  subjects 


LITPIOTRITY.  227 

are,  for  obvious  anatomical  reasons,  not  fit  subjects  for  litlio- 
tritj'  ;  lithotomy  leaving  nothing  to  be  desired  at  this  period 
of  life.  The  best  cases  for  the  procedure  are  adult  males,  with 
a  fair  state  of  the  general  health,  a  calculus  which  does  not 
exceed  one  inch  in  diameter,  and  a  sound  condition  of  the  genito- 
urinary organs,  that  is  to  say,  a  capacious  and  nonsensitive 
urethra,  a  normal  prostate,  a  bladder  capable  of  holding  a  few 
ounces  of  fluid,  and  freedom  from  renal  complications.  In  such 
persons,  who  are,  however,  rarely  met  with  in  actual  practice, 
crusliing  should  be  the  rule,  and  cutting  the  exception.  AVith 
regard  to  the  nature,  size,  and  number  of  the  stones,  it  may  be 
acce[tted,  that  uric  and  phosphatic  calculi  above  one  inch  and  a 
half  in  diameter,  and  oxalate  of  lime  concretions  more  than 
twelve  lines  in  diameter,  are  more  safely  dealt  with  by  lithotomy  ; 
and  the  same  rule  appertains  to  sacculated,  adherent,  and  mul- 
tiple large  calculi,  although  the  crushing  of  numerous  small 
stones  forms  no  greater  obstacle  to  success  than  dealing  with  so 
many  fragments.  Stricture  of  the  urethra,  unless  previously 
overcome,  and  the  full  dimensions  of  the  canal  restored,  is  a 
decided  contraindication.  Simple  enlargement  of  the  prostate 
merely  requires  careful  manipulations,  and  adds  somewhat  to 
the  difficulty  of  seizing  the  stone,  besides  necessitating  the 
removal  of  detritus  by  the  evacuating  apparatus.  When  tlie  hy- 
pcrti'ophy  is  not  uniform,  and  projects  mammillated  processes 
into  an  irritable  bladder,  and  the  calculus  exceeds  one  ounce 
in  weight,  particularly  if  it  be  composed  of  uric  acid  or  oxa- 
late of  lime,  lithotrity  is  not  justifiable.*  Malignant  disease, 
papillary  growths,  ulceration,  sacculation,  acute  inflammation, 
and  a  contracted  and  irritable  condition  of  the  bladder,  are 
positive  bars  to  the  operation  ;  while  a  mild  chronic  cystitis, 
which  can  he  alleviated  b}^  appropriate  measures,  and  is  asso- 
ciated with  a  soft,  small  stone,  is  not  a  serious  complication. 
Paralysis  of  the  bladder  renders  its  mucous  lining  much  more 
tolerant  of  the  presence  of  instruments,  and  is,  therefore,  not  an 
unfavorable  condition.  In  females  above  the  age  of  puberty, 
the  operation,  in  suitable  cases,  is  preferable  to  lithotomy,  pro- 

'  In  a  case  of  this  description,  under  the  care  of  the  editor,  acute  cystitis  and 
pelvic  cellulitis  terminated  fatallj'  on  the  fifth  day  after  gentle  manipulations. 
The  man  was  71  years  of  age,  and  had  been  lithotomized  eighteen  months  pre- 
viously.    Traus.  Path.  Soc.  Phila  ,  vol.  iv.  p.  1.13. 


228  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

vided  the  calculus  cannot  be  removed  entire  through  the  rapidly 
dilated  urethra.  Finally,  lithotrity  is  inadmissible  in  organic 
disease  of  the  kidney,  in  hyperfesthesia  of  the  urethral  mucous 
membrane,  with  a  tendency  to  urethral  fever,  and  in  persons  of 
feeble  health,  and  of  a  nervous,  irritable  constitution. 

Scarcely  less  important  than  the  proper  selection  of  cases,  is 
the  management  of  the  patient  previous  to  the  operation.  Under 
no  circumstances,  should  the  bladder  be  even  explored,  after  a 
long  journey,  until  the  patient  has  recovered  from  the  immediate 
effects  of  the  fatigue  and  the  local  irritation  which  is  almost 
sure  to  be  set  up  by  travelling.  After  the  preliminary  examina- 
tion, which  should  be  conducted  gently  and  not  extend  over  a 
period  of  more  than  two  or  three  minutes,  the  prudent  surgeon 
will  wait  for  forty-eight  hours,  to  see  whether  sounding  is  fol- 
lowed by  rigors  and  febrile  action.  If  the  subject  be  in  good 
health,  and  he  has  been  kept  in  bed  for  six,or  seven  days,  and  the 
urethra  does  not  resent  the  previous  instrumental  exploration, and 
is  sufficiently  capacious  to  permit  the  free  play  of  the  lithotrite, 
the  operation  may  be  proceeded  with  without  further  delay. 
Unless  these  precautions  be  attended  to,  the  surgeon  will  only 
have  himself  to  blame  in  the  event  of  failure  or  a  fatal  termina- 
tion. Morbid  sensibility  of  the  urethra  may  be  obtunded  by  the 
use  of  the  conical  steel  bougie,  along  with  weak  injections  of  ace- 
tate of  lead  and  opium,  and  the  internal  exhibition  of  bromide  of 
potassium.  Should  the  canal  require  dilatation,  it  is  best  ett'ected 
w'ith  the  same  instrument,  gradually  increasing  sizes  being  em- 
ployed until  the  object  is  accomplished;  and  the  meatus  may  be 
enlarged  by  a  slight  incision,  if  it  be  deemed  necessary.  The  urine 
must  be  examined,  with  a  view  to  detect  organic  renal  changes; 
and  any  chronic  cystitis  that  may  exist  should  be  met  by  appro- 
priate measures  until  the  bladder  is  enabled  to  hold  about  four 
ounces  of  urine  with  comfort.  If  the  patient  can  retain  his 
water  for  about  two  hours  in  the  morning,  that  amount  will 
have  been  secreted,  and  preliminarj'  injection  of  the  bladder  will 
be  rendered  unnecessary.  Annestheties  are  not  generally  re- 
quired, as  the  operation  is  not  painful  if  conducted  with  skill 
and  celerity,  and  it  is,  moreover,  desirable  that  the  patient  be 
able  to  inform  the  surgeon  of  any  undue  suftering. 

During  the  operation,  the  subject  should  lie  close  to  the  right 
edge  of  a  lirm  liair  mattress,  with  the  knees  separated  for  about 


LITHOTRITY 


229 


twelve  inches  and  supported  by  pillows,  and  the  pelvis,  which 
should  be  exposed  as  little  as  possible,  elevated  by  a  cushion  two 
or  three  inches  thick.  The  surgeon,  standing  on  the  right  side 
of  the  patient,  and  with  his  back  towards  the  head  of  the  bed, 
raises  the  penis  with  his  left  hand,  and  inserts  the  beak  of  the 
lithotrite,  the  shaft  of  which  rests  on  the  palmar  surface  of  the 
iingers  of  tlie  right*  hand,  held  over  the  spine  of  the  ilium,  into 
the  meatus,  when  he  draws  the  ])enis  over  it,  and  permits  the 
instrument,  as  be  carries  it  towards  the  median  line  and  gradu- 
ally raises  it  into  a  vertical  position,  to  find  its  own  way  to  the 
triangular  ligament.  This  point  having  been  reached,  the  penis 
is  drawn  still  further  upwards  on  the  lithotrite  which  is  now 
held  at  a  right  angle  with  the  body  of  the  patient,  through 
which  manamvre  the  beak  engages  in  tlie  membranous  urethra, 
when  the  handle  is  slowly  depressed  between  the  thighs  and  the 
beak  passes  through  the  prostatic  urethra  into  the  bladder. 

The  lithotrite  having  entered  the  bladder,  the  next  step  is  to 
find  and  seize  the  stone,  which  may  be  done  in  two  ways.  In 
tlie  first  method,  introduced  into  England  by  Heurteloup,  and 

Fiij.  62. 


Enslish  Metliod  of  Seizing  the  Stoae. 


practised  by  Brodie,  and  hence  known  as  the  English  method, 
the  lithotrite  is  moved  in  the  bladder  as  little  as  possible,  and 
the  fundus  of  the  viscus  is  made  the  area  of  the  early  manipula- 


230 


TREATMENT  OF  STOXE  IX  THE  BLADDER, 


tioi^s.  Tlie  handle  of  the  instrument  being  elevated,  the  male 
blade  is  withdrawn,  and  the  female  blade  is  pressed  against  the 
bas-fond  of  the  bladder,  as  represented  in  fig.  62,  from  Bryant, 
when  the  stone  falls  between  the  blades.  Should  it  not  do  so,  a 
number  of  quick  percussions  should  be  imparted  to  the  bladder, 
bj  giving  the  instrument  a  shake,  or  tapping  it  with  the  fingers, 
with  a  view  to  dislodging  the  calculus.  •In  the  second  and 
better  method,  which  Avas  practised  by  Civiale,  and  is  shown  in 
tig.  63,  from  Bryant,  the  instrument  is  njade  to  grasp  the  stone 


French  Method  of  Seizing  tlie  Stone. 


in  the  situation  in  which  it  may  be  detected,  contact  with  the 
walls  of  the  bladder  being  avoided  as  mucli  as  it  is  possible.  If 
the  calculus  is  felt  as  the  lithotrite  enters  the  bladder,  the  beak 
is  turned  slightly  away  from  it,  when  the  female  blade  is  pro- 
pelled onwards  and  the  male  blade  withdraAvn.  The  blades  are 
now  inclined  towards  the  stone,  which  is  almost  always  readilj' 
seized,  Avhen  they  are  closed.  Should  the  concretion  not  be  felt 
as  the  instrument  enters,  the  latter  must  be  carried  to  the  centre 
of  the  bladder,  wliero  the  blades  are  separated  and  carried  about 
the  eighth  of  a  circle  to  the  right  and  closed.  This  failing,  a 
similar  manoeuvre  is  practised  towards  the  left  side.  Should 
the  concretion  not  be  seized,  the  blades  are  to  be  slightly  raised 
from  the  floor  of  the  bladder  by  depressing  the  handle  of  the 
instrument,  opened,  and  turned  about  90°  or  one-fourth  of  a 
circle,  to  the  left,  and  closed,  then  to  the  right,  and  closed. 


LITHOTRITY. 


231 


Executed  in  this  way,  tliese  manipulations  will  rarely  fail  to 
detect  a  calculus.  When  the  prostate  is  enlarged,  when  the 
patient  is  very  corpulent,  or  in  searching  for  fragments  or  small 
concretions,  the  pelvis  must  be  elevated  from  four  to  six  inches, 
and  an  instrument  w' ith  short  blades  be  used,  in  order  that  they 
may  be  reversed.  The  handle  being  still  fai'ther  depressed,  and 
the  blades  separated,  and  brought  to  the  horizontal  position,  the 
latter  are  turned,  as  before,  first  to  the  right,  then  to  the  left, 
and  finally,  completelj"  reversed.  When  the  stone  is  large  and 
is  Icfdged  in  a  pouch  behind  the  prostate,  unless  the  male  blade 
is  fixed  at  the  neck  of  the  bladder  and  the  female  blade  projected 
onwards,  failure  is  inevitable. 

The  calculus,  having  been  seized  and  raised  to  the  centre  of  the 
bladder,  as  shown  in  fig.  64,  is  fixed  by  changing  the  sliding  into 
the  screwing  action  by  drawing  the  button  towards  the  handle, 
and  giving  the  wheel  a  slow  turn.  By  increasing  the  power, 
the  stone  soon  breaks  into  several  fragments,  when  the  screwing 

Fi-j.  G4. 


PositiuQ  of  Stone  foi'  Ciiibliiua 


motion  is  converted  into  the  sliding  motion,  and  the  male  blade 
withdrawn,  and  the  larger  fragments  successively  attacked. 
Xot  more  than  two  minutes,  however,  should  be  occupied  by 
the  first  sitting.  The  instrument  is  now  carefully  removed, 
care  being  taken  that  no  fragment  or  detritus  is  contained 
l)etween  the  blades,  as  may  be  ascertained  by  a  glance  at  the 
scale  on  the  male  rod.  Should  there  be  any  impaction  in  the 
female  blade,  it  may  be  gotten  rid  of  by  rapidly  forcing  the 
male  blade  in  and  out  by  alternating  turns  of  the  screw. 


232      TREATMENT  OF  STONE  IN  THE  BLADDER. 

Tlie  patient  is  put  to  bed  immediately  after  the  operation, 
wra[»ped  up  warmly,  and  kept  recumbent,  in  which  position  he 
is  to  pass  his  water,  for  at  least  forty  eight  Ijours,  to  prevent 
sharp  fragments  being  forced  against  the  vesical  orifice  of  tlie 
urethra.  A  hot  toddy,  and  a  hypodermic  injection  of  one-third 
of  a  grain  of  morphia,  will  materially  aid  in  warding  otf  rigors; 
his  diet  should  be  light,  and  he  should  be  allowed  an  abundance 
of  diluent  drinks.  As  soon  as  the  detritus  has  ceased  to  come 
away  with  the  urine,  which  usually  happens  in  four  or  five  days, 
provided  there  be  no  contraindications,  the  operation  should  be 
repeated,  with  a  lithotrite  with  plain  blades;  and  the  succeeding 
sittings  may  follow  at  short  intervals  and  be  prolonged  to  four 
or  five  minutes.  The  pulverization  of  the  last  fragments  requires 
great  manipulative  skill,  and  should  be  practised  with  a  litho- 
trite with  short  and  wide  plain  blades,  used  in  the  reversed  posi- 
tion, if  they  are  not  seized  in  the  ordinary  manner.  If  any 
fragment  remains  behind,  its  presence  will  be  denoted  by  a  little 
pain  and  the  escape  of  a  drop  or  two  of  blood  at  the  end  of 
micturition,  these  symptoms  being  increased  by  rough  exercise. 
Instead  of  pulverizing  the  fragments  and  permitting  the  detritus 
to  come  away  by  tlie  unaided  efforts  of  nature,  Sir  William 
Fergusson  prefers,  as  it  greatly  expedites  the  cure,  to  extract 
them  by  means  of  his  delicate  scoops.  Up  to  1867,  he  had  treated 
sixty  cases  in  this  way,  and  removed  some  unusually  large  frag- 
ments, with  the  effect,  however,  of  lighting  up  considerable  irri- 
tation of  the  neck  of  the  bladder. 

The  practice  of  injecting  the  bladder  to  wash  out  detritus  is 
obsolete.  In  cases,  however,  of  enlarged  prostate  and  paralysis  of 
the  organ,  its  contents  cannot  be  discharged  without  extrinsic 
aid.  Under  these  circumstances,  Fergusson's  scoops,  or  DitteFs  or 
Clover's  evacuating  apparatus,  may  be  employed  to  remove  the 
fragments.  The  apparatus  of  Mr.  Clover  is  composed,  as  seen 
in  fig.  65,  of  an  elastic  bottle,  attached  to  a  glass  reservoir,  into 
which  the  evacuating  catheter  projects  about  one  inch.  Having 
passed  the  catheter  and  drawn  off"  the  urine,  the  bottle,  filled 
with  warm  water,  is  attached,  and  the  catheter  gently  pressed 
against  the  bottom  of  the  bladder.  The  bottle  is  alternately 
slowly  compressed  and  rapidlj^  expanded,  the  outward  current 
bringing  with  it  the  fragments,  which  ftill  into  the  glass  cylinder. 
Should  the  stream  stop,  the  current  must  be  reversed,  to  send 


LITHOTRITY. 


233 


Fis;.  60. 


back  any  large  fragment,  that  may  obstruct  tbe  catheter,  into 
the  bladder.  This  apparatus  should  not  be  employed,  if  it  be 
possible  to  dispense  with  it,  as  its  use 
is  quite  as  irritating  as  lithotrity  itself. 
For  tills  reason,  evacuation  of  the 
debris  by  means  of  Professor  Dittel'si 
siphon  contrivance  is  perferable.  A 
long  piece  of  rubber  tubing  is  titted  to 
the  end  of  the  catheter,  while  the  other 
extremity  rests  in  a  receptacle  placed 
on  the  floor.  A  valvular  arrangement 
permits  an  inward  current  of  water, 
while  the  outflow  depends  upon  atmo- 
spheric pressure. 

The  accidents  and  bad  eftects  of  this 
operation  are :  rigors  and  fever ;  con- 
tusion and  laceration  of  the  urethra; 
impaction  of  fragments  of  the  calculus 
in  that  canal ;  prostatitis ;  epidid3miitis ; 
cystitis;  peritonitis;  pelvic  cellulitis; 
renal  irritation;  pyemia;  atony  of  the 
bladder;  hemorrhage;  perforation  of 
the  bladder ;  and  fracture  of  the  litho- 
trite. 

There  are  few  persons  Avho  do  not 
sufler  from  rigors,  or  an  attack  of  ure- 
thral fever,  after  the  procedure,  par- 
ticularly if  the  preparatory  treatment 

has  not  received  due  attention.  They  are  rarel}'  of  serious 
import  when  they  come  on  almost  immediately  or  within  a  few 
hours  ;  but  should  they  occur  after  the  lapse  of  forty-eight  hours, 
they  may  denote  an  outbreak  of  pyemia.  The  occurrence  of 
rigors  should  be  guarded  against  by  strict  recumbency,  warmth, 
a  brandy  toddy,  and  a  full  opiate  after  the  operation. 

Contusions  and  lacerations  of  the  urethra  will  be  most  likely 
to  take  place  when  there  is  a  disproportion  between  the  diameter 
of  the  canal  and  that  of  the  instrument,  especially  if  the  surgeon 
has  little  experience  in  operating ;  when  the  }>atient  is  restless 


Clover's  Ev;icuatiug  Apparatus. 


'  Practitioner.  3hirch,  1871,  p.  129. 


234  TREATMENT    OF    STONE    IN    THE    BLADDER. 

and  unmanageable ;  or  when  the  stone  is  unusually  large  and 
firm.  If  proper  precautions  be  used,  the  accident  can  scarcely 
happen. 

A  fragment  of  the  broken  calculus  is  sometimes  arrested  in 
the  urethra,  where  it  either  simply  produces  retention  of  urine, 
or,  in  addition,  more  or  less  irritation  of  the  mucous  membrane. 
If  tbe  piece  is  sharp  and  angular,  serious  mischief  may  ensue 
before  it  is  finally  dislodged.  If  it  is  situated  far  back,  an 
attempt  should  l)e  made  to  push  it  into  the  bladder  with  a 
catheter  or  a  stream  of  water;  or  these  failing,  it  should  be 
removed  by  a  median  incision.  If  it  has  advanced  considerably 
forwards,  it  may  be  extracted  with  a  curette,  or  the  forceps 
delineated  in  the  chapter  on  Foreign  Bodies  in  the  Urethra. 

A  not  uncommon  accident  after  lithotrity  is  the  occurrence  of 
traumatic  cystitis,  from  the  irritation  excited  by  sharp  and 
angular  fragments.  Instead  of  resorting  to  the  usual  remedies 
to  coml)at  the  inflammation.  Sir  Henry  Thompson^  has  recently, 
and  I  tliink  very  wisely,  recommended  that  the  patient  be  placed 
under  the  influence  of  an  anesthetic  agent,  and  the  fragments 
crushed  freely,  and  the  detritus  removed  by  Clover's  apparatus. 
Under  this  management  rapid  amelioration  of  the  symptoms 
ensues.  Another  point  to  which  this  practised  operator  calls 
attention,  is  that  unchecked  inflammation  of  the  l)ladder  is  liable, 
particularl}'  in  elderly  subjects,  to  lead  to  inability  on  the  part 
of  the  patient  to  empty  his  bladder,  wliereby  the  symptoms  are 
kept  up.  The  smallest  quantity  of  urine  retained  in  the  viscus, 
after  each  act  of  micturition,  leads  to  chronic  cystitis  and  phos- 
phatic  deposit.  The  treatment  is  to  cut  short  the  cystitis  by 
crushing  the  irritating  fragments,  and  the  methodical  introduc- 
tion of  Mercier's  catheter,  by  which  the  bladder  may  be  com- 
pletely drained  of  its  contents. 

Prostatitis,  epididymitis,  peritonitis,  and  pelvic  cellulitis  may 
occur  after  the  most  gejitle  manipulations  ;  but  they  need  not  be 
anticipated  unless  the  sitting  be  prolonged  or  is  productive  of 
suffering.     They  should  be  treated  on  general  principles. 

One  of  the  worst  effects  of  the  operation,  and  one  of  the  most 
frequent  sources  of  death  after  its  performance,  is  renal  inflamma- 
tion, followed  by  suppression  of  urine,  and  uremic  intoxication. 

'  Loudon  Lancet,  Jan.  8,  1870. 


LITHOTRITY.  235 

It  is  most  common  in  elderly,  irrital)le  subjects,  as  a  consequence 
of  antecedent  oro;anic  changes  in  the  kidneys,  which  were  diffi- 
cult or  impossible  of  detection  during  life.  The  chief  remedies 
are,  quinine,  milk  punch,  and  diaphoretics,  with  cupping  and 
hot  fomentations  to  the  loins. 

Next  to  renal  disorders,  the  most  frequent  cause  of  a  fatal  issue 
is  pyemia.  The  disease  is  usually  very  stealthy  in  its  character, 
and  affects  principally  old  subjects,  and  those  who  are  enfeebled 
by  dissipation  and  protracted  suffering.  Our  principal  reliance 
is  on  quinine,  opium,  stimulants,  nourishing  food,  and  free  inci- 
sions when  abscesses  have  formed. 

Atou}'  of  the  bladder,  with  I'ctention  of  urine,  is  liable  to 
occur  in  elderly  persons,  either  from  the  shock  received  by  the 
viscus  during  the  operation,  whereby  its  muscular  fibres  are 
temporarily  paralj'zed  ;  or  from  tumefaction  of  the  prostatic 
urethra. .  This  symptom  is  not  in  itself  of  dangerous  import  ; 
but  it  should  never  pass  unheeded,  lest  the  accumulation  of 
urine  proceed  too  far,  and  thereby  seriously  jeopard  life  from 
cystitis,  accompanied  with  a  low  form  of  fever  and  great  pros- 
tration. The  proper  remedy  is  the  catheter,  employed  at  stated 
intervals. 

Hemorrhage  is  not  an  infrequent  attendant  upon  the  oiieration  ; 
but  it  is  rarely  profuse  or  alarming.  In  the  event  of  its  occur- 
rence, it  should  be  treated  on  the  principles  laid  down  elsewhere. 

Perforation  of  the  bladder  has  sometimes  happened  in  the 
hands  of  the  most  skilful  operators.  The  same  thing  has  re- 
peatedly occurred  in  lithotomy,  so  that  it  cannot,  with  propriety, 
be  urged  as  an  ol)jection  against  lithotrity.  The  accident,  which 
is  a  most  serious  one,  as  it  is  usually  followed  by  infiltration  of 
urine  and  death,  may  be  caused  by  the  instrument  itself,  or  by 
a  sharp  corner  of  a  fragment  of  the  calculus. 

A  very  annoying  accident  is  fracture  of  one  of  the  blades  of 
the  lithotrite,  which  necessitates  attempts  at  its  removal  by  the 
forceps  or  by  cystotomy.  As  the  instruments  of  the  present  day 
are  cut  out  of  solid  pieces  of  steel,  and  arc  properly  tested,  little 
need  be  feared  from  this  source  of  eml)arrassment. 

As  a  substitute  for  ordinary  lithotrity,  when  the  calculus  is 
voluminous  or  veiy  hard,  or  when  the  bladder  is  irritaljle,  or 
there  is  a  predisposition  to  urinary  fever.  Professor  Dolbeau* 

'  De  la  Lithotritie  Perineale,  Paris,  1873. 


236  TREATMENT    OF    STONE    IX    THE    BLADDER. 

l>raetises  median  incision  of  the  mcmbranou^s  urethra,  dilates 
the  prostatic  portion  of  the  passage  and  tlie  neck  of  the  bladder, 
hy  means  of  an  instrument  composed  of  six  branches,  crushes 
the  stone  with  jiowerful  forceps,  and  at  once  removes  the  frag- 
ments with  small  forceps  and  the  scoop.  He  has  performed 
the  operation,  which  he  terms  perineal  lithotrity,  but  which 
diifers  only  from  lithectasy  in  removing  the  calculus  piecemeal, 
thirty  times  with  five  deaths,  and  does  not  limit  its  application 
to  any  particular  period  of  life.  He  claims  for  it  certain  advan- 
tages ;  but  that  it  possesses  any  over  lateral  lithotomy,  under 
the  same  circumstances,  I  am  at  a  loss  to  perceive. 

The  results  of  lithotrity  are  most  encouraging,  but  they  vary 
in  the  hands  of  different  operators.  The  operation  cannot  fairly 
be  compared  with  that  of  lithotomy,  since  the  cases  are  selected 
with  great  care,  and  are  those  whicli  are  most  favorable  for  the 
latter  procedure.  From  the  subjoined  table  of  1470  cases,  the 
mortality  is  seen  to  be  1  in  9.30. 


Sir  Henry  Thompson    . 

291 

cases, 

17  deaths, 

or  1 

in 

IT.ll 

Sir  Benjamin  Brodie     . 

115 

9 

in 

12.77 

Sir  William  Fer 

gnsson  . 

109 

12 

ill 

9.08 

Dr.  Keith 

l'2-l 

8 

in 

15.25 

Dr.  Ivancliich 

100 

13 

in 

7. 09 

Dr.  Swalin     . 

49 

i 

in 

Dr.  Buck 

55 

8 

in 

0.87 

]\rr.  Crichtou 

132 

8 

in 

15.25 

Mr.  Key 

12 

•)          " 

in 

4 

Leroy     . 

no 

11 

in 

10.55 

Ciizenave 

. 

52 

8 

in 

0.5 

Baliissa  . 

30 

5           " 

in 

0 

Billroth 

8 

3 

in 

2.00 

Norfolk  and  Noi 

wieh  Ilospiti 

1     34 

U           '■ 

in 

11.33 

Gny's  IIos))ital 

25 

n 

in 

4.10 

]\Ioscow  Clinic 

62 

fi        " 

in 

10.33 

Guersant 

21 

6 

in 

3.5 

Pennsylvania  H 

ospital 

14 

2           '• 

in 

7 

Porta      . 

13.3 

24           " 

in 

5.54 

1470 

159 

1 

in 

9.30 

Of  the  cases  occurring  at  the  Moscow  Clinic  and  the  Pennsyl- 
vania Hospital,  and  in  the  practice  of  Guersant  and  Porta,  106 
were  in  children. 

The  mortality  of  5014  lateral  lithotomies  in  the  private  and 
hcspital  practice  of  American  and  European  surgeons,  was  434, 


LITHOTRITY.  237 

or  1  in  12.92.  Hence,  if  a  comparison  be  made  between  the 
two  operations,  as  practised  at  all  ages,  the  recoveries  are  in  favor 
of  lithotomy.  More  than  one-half  of  the  cntting  operations 
were  performed  below  the  age  of  fifteen,  or  at  an  epoch  notori- 
onsly  fitted  for  lithotomy  and  unfitted  for  lithotrity.  In  adult 
subjects,  the  results  are  far  more  favorable  to  crusbing.  Thus, 
the  cases  of  Thompson,  Brodie,  Fergusson,  and  Keith,  in  the 
foregoing  table,  occurred  in  male  adults,  and  exliibit  a  loss  of  1 
in  13.84 ;  while  of  723  lateral  lithotomies,  tabulated  by  Sir  Henry 
Thompson,  in  the  same  class  of.  patients,  1  in  4.82  proved  fatal. 
A  comparison  of  the  two  procedures,  in  adults,  as  practised  by 
the  same  surgeons,  leads  to  similar  results,  since  of  231  cases  of 
lithotrity  in  the  hands  of  Keith  and  Fergusson,  20,  or  1  in  11.55, 
died,  while  of  296  lithotomies,  75,  or  1  in  3.94,  were  fatal. 

What  a  careful  selection  of  cases  is  capable  of  accomplishing 
for  calculous  cases  is  clearly  shown  by  the  results  of  the  practice 
of  Sir  Henry  Thompson.  Of  291  operations,  only  17,  or  1  in 
17.11,  died  ;  and  he  had  a  succession  of  51  elderly  cases  without 
a  single  death.  The  youngest  patient  was  twenty-two  years 
old,  and  the  eldest  eighty-four,  with  a  mean  age  of  upwards  of 
sixty.  ]!^ot  a  single  case  was  4eft  unfinished.  Of  his  last  87 
cases,  of  which  4  were  fatal,  he  has  been  enabled  to  trace  the 
relative  condition  of  45  to  a  period  varying  from  thirteen  months 
to  two  years  and  a  quarter  after  the  operation.  Eleven  have 
since  died,  six  of  urinary  disorders.  Of  the  34  living,  28  are  en- 
joying good  health  at  a  mean  age  of  sixty-three  and  a  half  years  ; 
and  6  have  some  signs  of  recurring  calculus,  two  having  had  a 
newly-formed  concretion  removed. 

In  estimating  the  comparative  value  of  the  two  operations,  it 
must  not  be  forgotten  tbat  relapse  is  about  five  times  more  fre- 
quent after  lithotrity  than  lithotomy,  which  is  doubtless  due  to 
the  ditficulty  in  removing  the  last  fragment,  which  l)ecoinesthe 
nucleus  of  a  new  formation,  in  the  former  procedure.  Thus  in 
the  practice  of  Thompson  it  occurred  once  in  every  twelfth  case, 
and  in  that  of  Oiviale  once  in  every  tenth.  In  the  jSTorfolk  and 
]Srorwich,  Luneville,  and  Charite  Hospitals,  the  Hospital  of  In- 
curables, at  jSTaples,  and  the  Saharunpore  Dispensary,  India,  on 
the  other  hand,  stone  recurred  sixty-two  times  in  thirty-eight 
hundred  and  two  cases  of  lithotomy,  or  once  in  every  sixty-one 
cases.  My  own  experience  has  atibrded  me  only  three  instances 
of  recurrence  in  140  cases. 


288  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

Sect.  V.— LITHOTOMY. 

It  would  be  an  endless  task  to  give  an  account  of  the  various 
operations  of  lithotom j,  as  they  have  been  practised  by  difterent 
surgeons  in  different  ages  and  in  various  parts  of  the  world. 
Hence,  I  shall  content  myself  with  an  account  of  a  few  of  the 
more  important  operations,  as  they  are  performed  by  the  most 
eminent  surgeons  of  the  present  day.  These  are  the  lateral, 
bilateral,  median,  suprapubic,  and  recto-vesical. 

Litliotomy  may  be  performed  at  any  period  of  life.  Experi- 
ence, however,  has  established  the  interesting  and  imp)0rtant 
fact  that  the  greatest  number  of  recoveries  take  place  in  children 
and  in  subjects  under  thirty  years  of  age.  Persons  after  this 
time  of  life  are  more  prone  to  sutfer  from  inflammation  of  the 
urinary  apjiaratus,  shock  to  the  sexual  organs,  erysipelas  of  the 
wound,  and  phlel)itis  of  the  neck  of  the  bladder  and  prostate 
gland.  Infanc}^  and  childhood  are  peculiarly  propitious  for  the 
operation.  The  disease,  at  this  period,  is  usually  free  from  com- 
plications, both  local  and  constitutional ;  the  wound  made  by 
the  knife  readily  heals  ;  traumatic  fever  seldom  runs  high  ;  and 
there  is  little  or  no  danger  of  urinary  infiltration,  erj'sipelas, 
phlebitis,  or  peritoneal  inflammation.  Other  advantages  are  the 
absence  of  mental  anxiety,  and  anticipation  of  an  unfavorable 
issue,  circumstances  which  often  exert  an  unhappy  influence 
upon  lithotomy  in  adults. 

It  need  hardly  be  said  that  every  patient,  about  to  undergo 
lithotomy,  should  be  subjected  to  a  certain  degree  of  preparatory 
treatment,  in  order  to  place  him  in  the  best  possible  condition 
to  bear  the  shock  and  other  ill  efl:ects  of  the  operation.  There 
is  no  doubt  that  much  of  our  success  depends  upon  the  manner 
in  Avhicli  this  is  done.  The  amount  of  this  preliminary  treat- 
ment must  necessarily  vary  in  different  cases,  and  does  not, 
therefore,  admit  of  precise  specification.  When  the  patient  is 
in  good  general  health,  as  is  evinced  by  the  state  of  his  com- 
plexion, appetite,  sleep,  and  digestion,  he  will  seldom  require 
anything  more  than  a  dose  or  two  of  aperient  medicine,  and 
abstinence  from  animal  food,  with  rest  in  his  room.  Four  or 
five  days  will,  in  fact,  generally  suffice  to  put  him  in  a  proper 
condition  for  the  operation.  But  it  is  very  difterent  when  he  is 
in  bad  health.      Here  a  more  thorough  course  of  preparatory 


LATERAL    LITHOTOMY.  239 

measures  is  necessary.  The  secretions  must  be  rectified,  the 
urine  must  be  brought  as  nearly  as  possible  to  the  healthy  stan- 
dard, the  bowels  niust  be  opened  by  mercurial  and  other  cathar- 
tics, the  diet  must  be  regulated,  and,  in  a  word,  all  sources  of 
excitement,  local  and  constitutional,  must  be  remov-ed.  When 
these  objects  have  been  attained,  then,  and  not  until  then,  will 
it  be  proper  to  subject  the  patient  to  the  knife.  Too  much 
preparation,  however,  should  be  avoided ;  for  it  is  as  bad  as 
too  little  ;  indeed,  if  anything,  worse. 

K^o  surgeon  having  a  proper  regard  for  his  own  character  and 
the  dignity  of  his  profession,  would  be  likely  to  operate  in  case 
the  patient  is  affected  with  organic  disease  of  the  lungs,  or  of 
any  other  important  viscera.  Serious  lesion  of  the  kidneys, 
ureters,  bladder,  and  prostate  gland  also  forbids  interference. 
In  short,  whenever  the  health  is  broken  down  by  previous  suf- 
fering, not  solely  dependent  upon  the  presence  of  the  urinary 
concretion,  the  judicious  surgeon  will  hesitate  not  a  little  before 
he  will  resort  to  the  knife. 

Persons  afl'ected  with  Bright's  disease  are  particularly  bad 
subjects  for  operations  for  stone  in  the  bladder,  by  whatever 
method  they  may  be  executed.  The  existence  of  this  form  of 
renal  disease  may  not,  in  its  earlier  stages  and  milder  grades, 
militate  against  the  performance  of  an  operation  ;  but  at  a  later 
period  no  interference  whatever  is  justifiable;  the  prognosis  is 
unfavorable,  and  no  care  that  can  be  bestowed  upon  the  patient 
will  be  likely  to  save  him.  Fortunately,  the  means  of  verifying 
the  presence  of  this  disease,  even  at  a  ver}-  early  period,  is  no 
longer  a  matter  of  doubt  or  difficulty.  The  scanty  quantity, 
diminished  density,  and  highly  coagulable  condition  of  tlie  uri- 
nary secretion,  along  with  the  presence  of  tube  casts,  the  feverish 
excitement  of  tlie  system,  the  steady  wasting  of  the  flesh  and 
strength,  the  pain  and  tenderness  in  the  lumbar  region,  the  fre- 
quent micturition,  and  the  tendency  to,  or  actual  existence  of, 
dropsical  effusion  in  various  parts  of  the  body,  are  unmistakable 
signs  of  the  coexistence  of  the  two  affections. 

Art.  I.— lateral  LITHOTOMY. 

Of  the  different  operations  for  stone,  the  lateral  is  by  far  the 
most  important,  not  only  on  account  of  its  greater  frequency, 


240  TREATMENT    OF    STONE    IN    THE    BLADDER. 

l)ut  also  on  account  of  the  reniarkablc  success  whicli  lias  hither- 
to attended  it.  In  the  descri})tion  whicli  I  am  about  to  give, 
I  shall  speak  of  it  as  I  am  myself  in  the  habit  of  executing  it, 
premising  that  this  does  not  ditfer,  in  any  essential  particular, 
from  the  method  devised  and  so  happily  practised  by  Cheselden 
and  his  disciples. 

The  design  of  the  lateral  operation  is  to  make  an  opening  on 
the  left  side  of  the  perineum,  extending  from  the  surface  of  the 
skin  through  the  prostate  gland  and  the  neck  of  the  bladder,  and 
large  enough  to  admit  of  the  easy  extraction  of  the  foreign  body. 
It  is  usually  described  as  consisting  of  three  steps,  or  stages. 
In  the  first,  the  surgeon  divides  the  skin,  the  connective  tissue, 
and  the  superficial  perineal  fascia ;  in  the  second,  the  transverse 
muscle,  the  triangular  ligament,  and  the  membranous  portion  of 
the  urethra ;  and  in  the  third  and  last,  the  prostate  gland,  and 
the  neck  of  the  bladder. 

The  wound  made  in  the  operation  may  be  said  to  represent  a 
truncated  cone,  the  apex  of  which  corresponds  with  the  neck  of 
the  bladder,  and  the  base  with  the  surface  of  the  perineum.  In 
the  adult,  its  extent  exfernalh'  varies  from  three  inches  to  three 
inches  and  a  half,  while  internally  it  does  not,  as  a  general  rule, 
exceed  eighteen  or  twenty  lines.  Its  superior  angle  is  an  inch 
and  a  quarter  above  the  verge  of  the  anus,  and  immediately  on 
the  left  side  of  the  raphe  of  the  perineum  ;  the  inferior,  on  the 
contrary,  is  usually  about  three-quarters  of  an  inch  to  an  inch 
below  the  anus,  and  a  little  nearer  to  the  tuberosity  of  the 
ischium  than  to  the  outlet  in  question.  The  inner  wall  of  the 
wound  corresponds  with  the  middle  line  of  the  perineum  ;  the 
external,  with  the  ramus  of  the  ischium  and  the  erector  muscle 
of  the  penis. 

a.  Mode  of  Operating. — The  evening  before  the  operation,  a 
brisk  purgative  is  administered,  to  clear  out  the  alimentary 
canal.  The  article  which  I  usually  select  for  this  jairpose  is 
castor  oil;  but  if  there  be  disorder  of  the  secretions,  as  indicated 
by  the  state  of  the  tongue  and  stomach,  a  combination  of  calomel 
and  rhubarb  with  a  few  grains  of  jalap  is  to  be  preferred.  If 
the  rectum  has  not  been  thoroughly  evacuated,  a  stimulating 
enema,  consisting  of  tepid  salt  water,  or  strong  soapsuds,  is  used 
a  few  hours  before  the  operation.  I  consider  it  of  paramount 
importance,  both  as  it   respects  the  safety  of  the   lower  bowel, 


LATERAL    LITHOTOMY.  241 

and  the  comfort  of  the  suro-eon,  that  this  precept  should  he  faith- 
fully attended  to  in  all  cases.  Moreover,  by  opening  the  bowels 
freely  immediately  before  the  operation,  there  Avill  be  no  neces- 
sity, as  a  general  rule,  for  any  purgative  medicine  for  two  or 
three  days  after.  The  operation  should  alwaj'-s  be  performed 
late  in  the  morning,  in  order  that  the  surgeon  may  have  a  good 
light,  not  only  at  the  time,  but  subsequently,  if  any  untoward 
occurrence,  such  as  hemorrhage,  should  arise.  The  patient's 
breakfast  on  the  day  of  the  operation  should  be  as  light  as  pos- 
sible, especially  if  it  be  designed  to  give  him  chloroform. 

The  urine  should  be  retained  for  several  hours  before  the  ope- 
ration ;  for  a  certain  degree  of  distention  of  the  bladder  is  neces- 
sary to  prevent  injury  of  its  walls,  and  facilitate  the  extraction 
of  the  foreign  body.  If  he  be  a  child,  and  cannot  hold  his  water 
without  great  difficulty,  a  piece  of  tape  should  be  tied  loosely 
around  the  penis  ;  otherwise  he  will  be  sure  to  disobey  an  injunc- 
tion wdiich  every  lithomist  must  regard  as  of  no  little  conse- 
quence. In  old  subjects,  affected  with  excessive  irritability  of 
the  bladder,  with  a  constant  desire  to  micturate,  it  is  necessary 
to  inject  the  organ  with  a  few^  ounces  of  tepid  water  just  before 
commencing  the  operation. 

During  the  operation  the  patient  lies  upon  his  back,  on  a 
narrow^  table,  about  four  feet  in  length,  and  provided  wnth  stout, 
iirm  legs,  to  prevent  it  from  shaking.  It  is  covered  with  a 
folded  blanket  or  comfortable,  over  which  are  spread,  first,  a 
piece  of  soft  oil-cloth,  and  next,  a  folded  sheet.  Several  pillows 
are  required  for  the  head  and  shoulders,  which,  however,  should 
be  but  slightly  raised,  otherwise  the  abdomen  will  be  doubled  up, 
and  unduly  compress  the  bladder.  The  breech  is  fully  exposed 
to  the  operator,  and  is  therefore  brought  well  down,  a  little  over 
the  edge  of  the  table. 

Two  stout  worsted  bands,  from  six  to  eight  feet  in  length  by 
two  inches  and  a  half  in  width,  are  required  to  bind  the  patient's 
limbs,  unless  he  be  aneesthetized,  wdien  they  are  not  needed. 
They  should  each  have  a  hole  in  the  middle  to  atford  greater 
security  against  their  slipping;  or  they  may  be  arranged  as  in  fig. 
66.  As  a  preliminary  step,  the  patient,  stripped  to  his  shirt, 
and  placed  upon  the  table,  is  desired  to  grasp  his  feet  in  such  a 
manner  as  to  apply  his  fingers  to  the  sole  and  the  thumb  to  the 
instep;  in  which  position  they  are  confined  b}'  means  of  the 
16 


242 


TREATMEXT    OF    STOXE    IX    THE    BLADDER, 


Fie;.  GG. 


Fillet. 


miets,  passed  around  tliem  in  the  form  of  the  figure  8,  the  ends 
heing  tied  in  a  double  knot,  or  fastened  with  stout  pins.  This 
duty  is  generally  confided  to  the  assistants,  for 
which  reason  it  is  often  discharged  so  badly  as 
to  be  followed  by  much  delay  and  annoyance ; 
the  patient,  perhaps,  becoming  untied  during 
the  operation.  A  careful  supervision  should, 
therefore,  always  be  exercised  in  this  respect  by. 
the  surgeon. 

The  limbs,  being  bound  or  not,  as  the  case 
may  be,  are  given  in  charge  of  two  assistants, 
who,  one  standing  on  each  side  of  the  patient, 
place  .one  hand  upon  the  top  of  the  knee,  and 
the  other  beneath  the  sole  of  the  foot.  AVheu 
the  operation  is  about  to  be  commenced,  the 
thighs  are  moderately  separated  from  each  other, 
and  held  nearl}'  at  a  right  angle  with  the  trunk. 
It  can  be  easily  perceived  how  important  it  must 
be,  in  reference  to  the  speedy  and  successful 
execution  of  the  operation,  that  the  patient's  limbs  should  b( 
thoroughh-  controlled,  and  out  of  the  surgeon's  way. 

It  is  usually  reeommend-ed  that  the  staff  should  be  introduced 
previously  to  the  ligation  of  the  jTatient ;  but  to  such  a  procedure 
I  am  altogether  averse,  because  it  is  productive  of  serious  annoy- 
ance to  the  patient,  and  is  almost  sure  to  be  followed  by  a 
premature  escape  of  the  urine.  Besides,  it  is  a  source  of  incon- 
venience to  the  persons  who  have  charge  of  the  limbs.  My 
rule,  therefore,  always  is  to  tie  the  patient  first,  and  immediatelji 
after  to  introduce  the  staff;  taking  care  to  confide  it  to  a  good, 
intelligent  assistant,  one  who  is  thoroughly  acquainted  with 
the  anatomy  of  the  pelvis,  and  the  different  steps  of  the  operas 
tion.  During  the  operation,  the  instrument  is  to  be  held  per- 
pendicularly, with  the  handle  nearly  at  a  right  angle  with  the 
trunk,  and  inclined  slightly  towards  the  right  side.  The  curved 
portion,  securely  lodged  in  the  bladder,  is  hooked  up  closely 
against  the  pubic  symphysis.  The  object  of  this  advice  is  to 
prevent  the  instrument  from  pressing  upon  the  rectum,  which 
would  thus  be  in  danger  of  being  wounded.  By  inclining  the 
handle  of  the  staff"  a  little  towards  the  right  groin,  the  curved 
portion  is  made  to  bear  against  the  left  side  of  the  perineum, 


LATERAL    LITHOTOMY. 


243 


with  the  effect  of  rendering  it  somewhat  prominent  and  thereby 
facilitating  the  division  of  the  membranous  portion  of  the 
urethra.  The  assistant  having  charge  of  the  instrument  stands 
on  the  left  side  of  the  patient,  in  order  that  he  may  use  his 
right  hand,  and  also  hold  the  scrotum  out  of  the  way. 

The  stafl",  represented  in  fig.  67,  is  made  of  steel,  and  is  about 
ten  inches  in  length,  exclusive  of  the  handle,  which  should  be 


Fia;.  67. 


Fiff.  ea 


Fio;.  69. 


Grooved  Staff. 


Lilhotoiuy  KnilV 


Benked  Knife. 


at  least  two  inches  long  by  two  lines  and  a  half  in  thickness 
and  fifteen  lines  in  width,  and  perfectly  rough  on  the  surface, 
that  it  may  be  the  more  securel}^  held  in  the  hand.  The  groove, 
placed  a  little  towards  the  left  side,  and  extending  from  near 


244  TREATMENT    OF    STONE    IN    THE    BLADDER. 

the  middle  of  the  instrument  to  within  a  short  distance  of  its 
beak,  should  be  perfectly  smooth,  and  as  deep  and  as  wide  as 
possible.  It  is  warmed  and  oiled,  previously  to  its  introduction, 
like  an  ordinary  catheter,  and  should  be  large  enough  to  distend 
the  urethra  to  as  g^-eat  a  degree  as  is  compatible  with  the 
patient's  comfort.  By  adopting  this  advice,  the  surgeon  will 
find  it  comparatively  easy  to  find  the  staff,  and  effect,  in  a  safe 
and  proper  manner,  the  division  of  the  prostate  gland  and  the 
neck  of  the  bladder.  AVith  the  straight  staff  of  Mr.  Aston  Key, 
which  is  the  form  of  the  instrument  usually  employed  at  Guy's 
Hospital,  I  have  no  personal  experience. 

The  surgeon,  during  the  operation,  sits  upon  a  low,  firm  chair, 
or  stool,  as  he  may  find  it  most  convenient.  Or  he  may  place 
himself,  as  I  usually  do,  in  the  half-kneeling  posture,  resting 
upon  the  right  knee.  I  generallj^  prefer  this  posture,  because  it 
affords  greater  freedom  to  my  hands  and  elbows,  by  placing 
them,  as  it  were,  in  a  more  depending  situation.  To  protect 
his  person  and  clotlies  from  blood,  urine,  and  feces,  he  should 
wear  a  long  India-rubber  apron.  A  piece  of  old  carpet,  or  a 
sheet,  is  laid  upon  the  floor,  under  the  patient's  breech,  to  re- 
ceive the  fluids. 

The  knife  which  I  have,  for  many  years,  been  in  the  habit  of 
using,  is  the  one  sketched  in  fig.  68.  It  is  very  light  and  slender, 
shar}>pointed,  and  nearly  seven  inches  in  length,  of  which  three 
are  occupied  by  the  blade,  which  hardly  exceeds  two  lines  in 
width.  For  enlarging  the  opening  in  the  prostate  and  neck  of 
the  bladder,  after  the  withdrawal  of  the  staflP,  I  sometimes  use 
the  probe-jjointed  bistour}',  delineated  in  fig.  69,  although  the 
former  instrument  is  quite  as  safe,  provided  the  extremity  be 
carefully  guided  along  the  index  finger  as  it  lies  in  the  bottom 
of  the  wound.  Instead  of  the  ordijiary  knife,  some  surgeons 
still  iDrefer  the  gorget  or  single  lithotome  cache,  for  making  the 
deep  incisions.  Although  these  instruments  have  almost  fallen 
into  desuetude,  the  former  will  serve  a  useful  purpose  when 
the  depth  of  the  perineum  is  greatly  increased  by  an  enlarged 
prostate. 

Everything  being  thus  prepared — the  rectum  cleared  out,  the 
instruments  arranged  on  a  tray,  the  limbs  tied  and  held  out  of 
the  way,  the  staft"  in  the  bladder  and  in  the  hand  of  the  assistant, 
the  breech  projecting  over  the  table,  and  the  patient  fully  unjer 


LATERAL    LITHOTOMY. 


245 


the  influence  of  chloroform — the  operator  is  reach*  to  hegin. 
Introducing  the  index  finger,  well  oiled,  into  tlie  bowel,  to 
induce  it  to  contract,  and  to  enable  him  to  ascertain  the  position 
of  the  staff,  and  marking  with  his  eye  the  situation  of  the  tube- 
rosity of  the  ischium,  he  stretches  the  integument  of  the  perineum 
with  the  thumb  and  fingers  of  the  left  hand,  and  commences 
his  incisions.  The  knife  is  entered  just  by  the  side  of  the  raph^, 
on  the  left  half  of  the  perineum,  an  inch  and  a  quarter  above 
the  margin  of  the  anus,  and  is  carried  obliquely  downwards  and 
outwards,  a  short  distance  below  the  tuberosity  of  the  ischium, 
and  a  little  nearer  to  this  point  than  to  the  anus.  If  the  part 
is  unusually  full,  the   instrument   is   plunged    in  at  the  fii-st 


Fiff.  70. 


Tlie  Finger  and  Knife  in  the  Groove  of  the  Staff. 

stroke  to  the  depth  of  at  least  one  inch  ;  otherwise  it  must  be 
used  more  cautiously.  As  the  knife  descends,  it  is  gradually 
withdrawn  from  its  deep  position,  so  as  to  give  the  wound  a 
sloping  appearance.  The  length  of  the  incision  must  be  regu- 
lated by  the  size  of  the  perineum  and  the  age  of  the  patient ; 
but,  in  the  adult,  it  should  not,  in  general,  be  less  than  three  to 
three  inches  and  a  half.  In  the  young  subject  it  must  be  pro- 
portionately smaller. 

Placing  the  point  of  the  left  index-finger  in  the  upper  angle 
of  the  wound,  the  knife  is  reentered  just  by  the  side  of  it,  and 
is  made  to  divide,  by  repeated  touches  with  its  edge,  the  super- 
ficial perineal  fascia,  the  transverse  muscle,  and  a  portion  of  the 


246  TKEATMEXT    OF    STOXE    IX    THE    BLADDER. 

triangular  ligament,  with  a  few  of  the  fibres  of  the  elevator 
muscle.  The  membranous  portion  of  the  urethra  being  thus 
exposed  a  little  in  front  of  the  prostate  gland,  the  surgeon  feels 
for  the  groove  of  the  staff,  at  the  bottom  of  the  wound,  and 
having  found  it,  he  cuts  into  it  through  the  denuded  tube,  as  in 
fig.  70.  The  length  of  the  opening  in  the  urethra  need  not  ex- 
ceed the  third  of  an  inch. 

The  knife,  inserted  into  the  groove  of  the  staft',  through  the 
opening  in  the  urethra,  is  now  carried  on  into  the  bladder, 
dividing,  as  it  passes  along,  the  neck  of  the  organ  and  the  left 
lobe  of  the  prostate,  in  a  direction  obliquely  downwards  and 
outwards,  which  is  in  that  of  its  long  axis.  In  executing  this 
step  of  the  operation,  the  rectum  is  to  be  held  out  of  the  way, 
by  pressing  it  over  towards  the  right  side  with  the  left  index- 
finger,  which  should  be  steadily  kept  in  the  bottom  of  the  wound, 
from  the  moment  of  the  first  incision.  Great  care  should  also 
be  taken  not  to  prolong  the  incision  in  the  prostate  gland  too 
far  back,  for  fear  of  penetrating  the  reflection  of  the  pelvic  fascia 
and  the  adjacent  venous  plexus. 

As  soon  as  the  bladder  has  been  opened,  the  urine  escapes, 
generally  in  a  gush  ;  the  knife  is  now  removed,  and  the  finger, 
lying  in  the  bottom  of  the  wound,  is  carried  into  the  bladder 
along  the  stafi",  which  is  immediately  withdrawn.  The  urine, 
as  it  passes  oft",  frequently  forces  the  calculus  down  against  the 
artificial  opening,  so  as  to  aftbrd  the  surgeon  an  opportunity  of 
ascertaining  its  form  and  bulk.  When  this  does  not  happen, 
the  finger  is  carried  into  the  bladder  to  its  full  length,  and  used 
as  a  searcher.  If  the  stone  is  found  to  be  disproportionately 
large,  the  wound  must  be  immediately  dilated,  either  with  the 
finger  or  the  bistoury,  according  as  the  resistance  may  seem  to 
depend  upon  the  prostate  or  the  muscular  structures.  In  elderh* 
subjects,  the  instrument  will  generally  be  necessary,  as  the  gland 
is  not  sufficientl}'  lacerable  to  yield  to  pressure. 

The  incisions  being  completed,  the  next  step  of  the  operation 
is  to  extract  the  calculus.  This  is  done  with  the  forceps,  fig. 
71,  which  are  conveyed  into  the  bladder  along  the  upper  surface 
of  the  index  finger,  lying  in  the  bottom  of  the  wound,  in  con- 
tact with  the  foreign  body.  The  forceps  are  introduced  with 
the  blades  closed,  and  are  used  at  first  as  a  searcher.     As  soon 


LATERAL    LITHOTOMY. 


247 


as  they  are  brought  in  contact  witli  the  concretion,  the  blades 
are  expanded  over  it,  in  tlie  direction  of  its  long  axis,  and  with 


Fis.  71. 


Lithotomy  Forceps. 


a  firm  grasp,  as  seen  in  fig.  72,  to  prevent  the  risk  of  slipping. 
Taking  care  that  the  instrument  does  not  embrace  anv  of  the 
folds  of  the  mucous  membrane,  the  operator  endeavors  to  extract 
the  foreign  substance  by  gently  moving  the  forceps  from  side  to 


Fig.  73. 


Mode  of  Seizing  and  Extracting  the  Stone. 

side,  or  upwards  and  down-wards,  on  the  same  principle  as  in  the 
delivery  of  the  child's  head.  The  facility  wdth  wdiich  the  stone 
may  be  seized  depends  upon  circumstances.  In  general,  it  lies 
in  contact  with  the  inner  extremity  of  the  wound,  and  may  be 
readily  caught  in  the  embrace  of  the  blades  of  the  instrument. 
Sometimes,  however,  as  when  it  is  lodged  in  the  bas-fond  of  the 


248  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

organ,  it  refuses  to  come  down,  and  may  tlius  embarrass  the 
young  operator.  The  diiRculty,  as  will  be  particularly  mentioned 
hereafter,  is  easily  remedied  by  inserting  the  finger  into  the 
rectum,  and  pushing  the  concretion  forwards  against  the  forceps. 
When  the  stone  is  situated  in  the  superior  fundus  of  the  bladder, 
the  forceps  must  be  carried  high  up,  in  the  direction  of  the  long 
axis  of  the  pelvis,  where  they  are  to  be  moved  about  as  a  searcher. 
Occasionally,  it  lies  behind  the  pubic  symphysis,  and  cannot  be 
seized  until  it  has  been  dislodged  by  pressure  upon  the  inferior 
part  of  the  hypogastric  region,  aided  by  the  finger  in  the  bladder. 
If  the  calculus  is  very  small,  it  is  sometimes  more  easily  ex- 
tracted with  the  scoop,  tig.  73,  than  with  the  forceps.     The  same 

Fi-  73. 


Lithotomy  Scoop. 

instrument  should  also  be  used  when  the  concretion  has  been 
broken,  whether  accidentally  or  designedly,  into  fragments,  which 
must  then  be  removed  piecemeal.  The  scoop  is  about  ten  inches 
in  length,  and  is  shaped,  as  its  name  indicates,  at  each  extremity, 
like  a  spoon.  An  instrument  like  this  ma}'  be  made  very  service- 
able in  extracting  an  adherent,  encysted,  or  impacted  concretion. 
As  soon  as  the  foreign  bod}-  has  been  extracted,  the  bladder  is 
washed  out  with  tepid  water,  thrown  up)  in  a  full  stream  from  a 
large  syringe.  Any  pieces  or  fragments  that  may  have  escaped 
the  forceps  or  scoop  are  thus  removed ;  otherwise  there  will 
almost  certainly  be  a  return  of  the  calculous  affection,  the  smallest 
particle  frequently  serving  as  a  nucleus  for  a  new  concretion. 
The  syringe  which  1  prefer  is  capable  of  holding  twelve  ounces, 
and  is  provided  with  a  nozzle,  four  inches  in  length,  slightl}' 
curved  to  adajtt  it  to  the  axis  of  the  pelvis,  and  terminating  in 
a  small  ivory  ball,  perforated  by  several  small  eyelets.  The 
bladder  having  been  washed  out  in  the  manner  here  mentioned, 
a  female  sound  is  next  introduced  through  the  wound  into  the 
interior  of  the  viscus,  and  used  as  a  searcher  with  the  view  of 
ascertaining  whether  any  stones  or  fragments  have  been  left 
behind.     Should  this  be  the  case,  the  forceps,  scoop,  and  syringe 


LATERAL    LITHOTOMY.  249 

are  again  used  till  complete  clearance  is  effected.  In  general, 
when  the  stone  is  rough,  it  is  an  evidence  that  it  is  solitary;  but 
to  this  rule  there  are  occasional  exceptions.  The  operation  being 
finished,  the  patient  is  unbound,  and  conveyed  to  his  bed,  a  piece 
of  oil-cloth  and  a  folded  sheet  being  placed  under  his  breech, 
to  protect  the  clothing,  and  absorb  the  urine. 

j3.  Extent  of  the  Incision  of  the  Prostate. — There  is  probably 
no  subject  connected  with  the  lateral  operation  of  lithotomy 
respecting  wliich  more  diversity  of  opinion  has  been  entertained 
than  that  which  relates  to  the  extent  to  which  the  incision  in 
the  prostate  gland  should  be  carried.  This  contrariety  of  opinion, 
hoAvever,  exists  in  a  much  less  degree  now  than  it  did  formerly. 
Modern  lithotomistsseem  to  be  pretty  well  agreed  that  the  divi- 
sion should  always  be  as  limited  as  it  can  be  consistently  with 
the  safe  and  easy  extraction  of  the  foreign  body.  In  my  own 
operations  I  have  strictly  adhered  to  this  rule,  and  have  never 
had  any  occasion  to  regret  it,  but  quite  the  reverse.  The  wound 
should  in  no  instance,  however  bulky  the  stone  may  be,  extend 
entirely  through  the  lateral  lobe  of  the  prostate,  on  account  of 
the  danger  of  urinary  infiltration  from  division  of  the  vesical 
reflection  of  the  pelvic  fascia.  "When  the  concretion  is  very 
voluminous,  it  should  either  be  broken,  and  extracted  piecemeal, 
or,  wliat  is  better,  the  opening  should  be  enlarged  by  incising 
the  opposite  half  of  the  gland.  If  this  do  not  afford  sufficient 
room,  the  only  resource  is  to  crush  the  calculus,  or  to  remove  it 
by  the  suprapubic  or  rectal  section.  In  ordinary  cases,  where 
the  foreign  body  is  of  moderate  dimensions,  I  incise  the  organ 
to  a  very  limited  extent,  and  immediately  after  enlarge  the 
opening  with  the  finger,  the  pressure  of  which  is  generally  suffi- 
cient for  the  purpose.  When  it  is  not,  the  probe-pointed  bistoury 
is  used  as  a  substitute.  It  is  remarkable  how  lacerable  the  organ 
is  in  children  and  adolescents,  and  to  what  extent  it  may  be  torn, 
without  endangering  the  parts  by  infiltration.  In  old  subjects, 
especially  such  as  liave  labored  for  a  long  time  under  induration 
and  enlargement  of  the  gland,  the  division  is  generally  obliged 
to  be  effected  with  the  bistoury. 

In  childhood  and  early  boyhood,  or  up  to  the  twelfth  year,  the 
division  of  the  entire  gland  is  absolutely  essential  to  the  intro- 
duction of  the  finger  and  the  forceps  into  the  bladder,  and  the 
extraction  of  the  calculus.    I  am  con  ti dent  that  this  has  happened 


250  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

in  all  my  operations,  sixt3'-Bix  in  nuinLor,  and  I  have  vet  to  meet 
with  a  solitary  instance  in  which  the  ]>rocedure  was  followed  by 
intiltration  of  urine.  The  annexed  drawings,  figs.  74,  75,  and 
76,  copied  from  personal  dissections,  exhibit  the  size  and  shape 
of  the  prostate  at  birth  and  at  four  and  twelve  years. 

Fi.r.  74.  Fig.  75.  .    Fi^.  76. 


Fig.  74.  Prostate  at  birth  Width,  at  base,  4  lines  ;  a  little  above  middle,  5  lines  ;  at  apex,  2 
lines  ;  leugth  along  the  middle,  4  lines,  and  at  the  edge,  41 ;  thickness  at  base,  2  lines  ;  at  middle, 
3i- ;  and  at  apex,  1|.     Weight,  13  gVHius. 

Fig.  7o.  Prostate  at  4  years.  Breadth  at  base,  6  lines:  just  above  the  middle,  7  ;  and  at  Ihe 
apex,  2i ;  length  along  the  middle,  6  lines  ;  and  7  lines  at  Ihe  margin ;  thickness  at  base,  2J  line.s ; 
at  the  middle,  4  ;  and  at  apex,  2.     Weight,  23  grains. 

Fig.  76.  Prostate  at  12  years.  Width,  8j  lines,  at  base;  ftj  above  the  middle,  and  3  at  apex; 
length  along  the  middle,  S  lines,  and  8}  at  the  edge;  thickness  at  base,  3  ;  middle,  4^  ,  and  at  apex, 
2f.     Weight,  43  grains. 

Lithotomy  in  impubic  subjects  is  generally  one  of  the  simplest 
and  easiest  of  surgical  procedures.  My  practice  now  invariably 
is  to  make  a  small  external  incision,  and,  after  opening  the  mem- 
branous urethra  and  the  apex  of  the  prostate,  to  divide  the  re- 
mainder of  the  gland  and  neck  of  the  bladder  Avith  the  finger. 
This  can  always  be  done  with  the  greatest  facilit}',  while  the 
pelvic  fiiscia,  being  indisposed  to  tear,  offers  a  mechanical  obstruc- 
tion to  the  finger,  whereby  the  dangers  of  cellulitis  and  urinary 
infiltration  are  reduced  to  a  minimum.  To  prevent  the  knife 
from  passing  between  the  bladder  and  the  rectum,  the  index 
finger  should  be  kept  in  close  contact  with  the  upper  angle  of 
the  wound,  just  below  the  arch  of  the  pubes,  while  the  handle  of 
the  knife  should  be  depressed  towards  the  lower  angle  of  the 
wound,  through  whicli  manoeuvre  its  point  is  well  raised  and 
kept  in  the  groove  of  the  staff,  otherwise  the  instrument  may 
pierce  the  prostate,  and  even  the  base  of  the  bladder,  and  the 
finger  form  a  cavity  in  the  loose  connective  tissue  of  the  recto- 
vesical space,  and  thus  lead  to  the  idea  that  the  bladder  has  been 
penetrated,  when,  in  reality,  it  has  not  been  opened  at  all.  The 
staff  should  not  be  withdrawn  until  the  surg-eon  is  assured  that 


LATERAL    LITHOTOMY.  251 

tlie  finger  is  fully  in  the  organ,  or,  if  possible,  in  contact  with 
tlie  stone. 

y.  Extent  of  the  External  Incision. — Quite  different  is  it 
with  regard  to  the  outer  wound  in  the  adult.  While  the  in- 
ternal should  alw'ays  be  small,  the  external  can  scarcely  be  too 
large,  or  too  free  and  dependent.  The  extent  of  the  outer 
wound  should  never  be  less,  in  the  adult,  than  three  inches  to 
three  inches  and  a  half;  in  very  young  subjects  it  must,  of 
course,  be  proportionately  limited,  but  even  in  them  it  sliould 
rarely  be  less  than  two  inches.  There  is  no  little  risk  of  uri- 
nary infiltration  where  the  external  wound  is  small  and  ele- 
vated ;  for  it  serves  to  retain  tlie  water,  as  in  a  sort  of  reservoir, 
and  enables  it  to  fret  and  irritate  the  deep  portions  of  the  w^ound, 
before  they  have  received  a  glazing  of  plastic  matter.  The  rule, 
then,  in  regard  to  this  subject  is  briefly  and  simply  this,  a  small 
internal  incision,  and  a  free  external  one. 

Difliculties  of  Extraction. — Difliculty  frequently  occurs  in 
the  extraction  of  the  stone.  This  may  depend,  first,  upon  the 
stone  itself;  secondly,  upon  the  bladder ;  and  thirdly,  upon  the 
pelvis. 

1st.  The  difliculty  may  be  caused  b}-  the  lodgment  of  the  stone 
in  the  bas-fond  of  the  bladder,  which,  in  old  subjects  afl'ected 
with  enlargement  of  the  prostate  gland,  is  often  converted  into 
a  sort  of  cul-de-sac.  A  concretion,  especially  when  of  inconsider- 
able volume,  may  be  so  deeply  buried  here  as  to  elude  every 
attempt,  on  the  part  of  the  surgeon,  to  seize  it.  The  remedy  is 
to  raise  the  stone  up,  and  place  it  within  reach  of  the  instru- 
ment, with  the  left  index-finger  inserted  into  the  rectum. 

The  stone  is  sometimes  lodged  above  the  pubes,  from  which 
it  may  refuse  to  descend  to  the  inferior  part  of  the  organ. 
When  this  is  the  case,  an  attempt  should  be  made  to  displace 
it  b}'  compressing  the  hypogastrium,  after  thorough  relaxation 
of  the  abdominal  muscles.  Should  this  fViil,  a  strong  probe, 
bent  into  a  hook,  may  be  used,  or  it  may  be  drawn  down  wnth 
the  point  of  the  index-finger. 

2d.  The  stone  may  be  entangled  in  the  folds  of  the  mucous 
membrane  ;  or  it  may  be  spasmodically  grasped  by  the  bladder, 
which  may  thus  prevent  the  blades  of  the  forceps  from  lieing 
expanded  over  it.     In  the  former  case,  the  scoop  replaces  the 


252  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

forceps ;  or,  if  this  fail,  dislodgment  may  be  attempted  by 
throwing  cold  water  into  the  bladder,  in  a  full  stream,  from  a 
laro-e  syrino-e.  In  the  latter  case,  the  surgeon  desists  for  a  few 
minutes,  until  the  organ  relaxes  its  convulsive  grasp,  when  the 
foreign  body  is  seized  and  extracted  Should  the  spasm  be 
severe  and  refuse  so  j'ield,  it  may  be  overcome  by  anaesthetics. 

3d.  It  sometimes  happens  that  the  stone  is  encysted  or  .i:)artly 
encysted,  and  partly  free.  When  this  is  the  case,  the  finger 
should  be  introduced  into  the  bladder  and  the  cyst  ruptured 
with  the  nail,  or  a  probe-pointed  bistoury,  or  a  knife  fashioned 
like  a  gum  lancet,  and  furnished  with  a  long  handle.  A  similar 
procedure  may  be  employed  when  the  calculus  has  been  rendered 
adherent  b}'  a  mass  of  organized  lymph  ;  or  when  it  is  embedded 
in  the  wall  of  the  bladder,  impacted  in  the  orifice  of  the  ureter, 
or  lodged  in  the  bodj-  of  the  prostate  gland.  Embarrassment 
may  be  occasioned  by  the  presence  of  a  urinarj-  pouch  between 
the  bladder  and  the  rectum,  as  happened  to  Mr.  Hancock,  of 
London.  Thebladder  itself  was  much  contracted,  and  contained 
the  calculus,  which  the  instrument  had  thus  been  prevented 
from  reaching.^ 

4th.  It  ma}'  be  difficult  to  seize  the  stone  on  account  of  the 
great  depth  of  the  perineum,  attended,  perhaps,  with  an  extraor- 
dinary length  of  the  bladder.  Such  an  occurrence  is  rare  in 
children,  but  not  infrequent  in  old  and  stout  subjects.  The 
remedy  consists  in  making  firm  pressure  upon  the  bladder  just 
above  the  pulses,  by  which  the  stone  is  forced  down  into  the 
lower  part  of  the  viscus. 

5th.  The  stone,  under  the  grasp  of  the  forceps,  may  break  into 
numerous  fragments,  be  reduced  to  a  soft,  pulpy  mass,  or  be 
crushed  into  small  sandy  particles.  If  the  fragments  are  large, 
they  may  be  extracted  with  the  forceps ;  if  small,  with  the 
scoop  and  syringe,  with  which  the  cavity  of  the  bladder  should 
be  thoroughly  washed  out  by  throwing  into  it  copious  and  re- 
peated streams  of  tepid  water. 

6th.  Delay  and  inconvenience  may  arise  from  the  presence  of 
a  considerable  number  of  calculi.  AVhen  the  stones  are  multiple, 
the}'  should  be  extracted  one  after  another,  either  with  the 
forceps,  or  with  the  forceps  and  scoop.     The  repeated  introduc- 

'  B.  B.  Cooper's  Lectures  on  Surgery,  p.  488.     Pliiladelphia,  1853. 


LATERAL    LITHOTOMY.  253 

tion  of  these  instruments,  if  properly  conducted,  is  rarely  pro- 
ductive of  much  inconvenience  ;  on  the  contrary,  it  is  astonishino- 
how  well,  in  general,  the  operation  is  borne.  It  is  only  when 
the  V)ladder  or  the  neighboring  parts  are  severely  irritated, 
bruised,  or  lacerated,  that  serious  mischief  is  to  be  apprehended. 

7th.  Extraction  may  be  rendered  difficult  by  the  fracture  of 
the  asjierities  of  the  calculus.  Of  this  I  had  a  remarkable 
instance  in  a  gentleman  whom  I  cut  some  years  ago.  The 
stone  was  covered  with  long  spines,  a  number  of  which  broke 
oft"  under  the  pressure  of  the  forceps,  which,  in  consequence,  I 
was  obliged  to  reintroduce  at  least  six  or  eight  times,  before  I 
was  able  to  maintain  my  hold  with  sufficient  force  to  eti'ect 
extraction. 

8th.  Embarrassment  and  delay  may  proceed  from  the  manner 
in  which  the  stone  is  grasped.  It  is  hardly  necessary  to  state 
that  the  concretion  should  always,  if  possible,  be  seized  by  the 
forceps  by  its  smallest  diameter ;  but  the  reverse  may  happen, 
and  then  the  extraction  will,  of  course,  be  rendered  [troportion- 
ately  difficult.  When  the  surgeon  has  reason  to  believe  that 
the  calculus  has  been  seized  by  its  longest  diameter,  the  finger 
should  be  at  once  introduced  into  the  wound  to  ascertain  the 
fact,  and  be  prepared,  if  need  be,  to  assist  in  changing  the  posi- 
tion of  the  foreign  body.  Before  this  can  be  done,  however, 
the  forceps  must  relax  their  hold  upon  the  calculus,  but  it  is  not 
necessary  to  withdraw  them  from  the  bladder.  For  want  of 
attention  to  this  point,  great  injury  is  sometimes  done  to  the 
neck  of  the  bladder,  as  well  as  great  delay  experienced  in  re- 
moving the  concretion. 

9th.  Embairassment  occasionally  results  from  an  inability  to 
find  the  concretion  after  the  bladder  has  been  opened.  This 
may  depend  upon  some  of  the  causes  already  detailed  ;  or  it  may 
be  owing  to  the  expulsion  of  the  stone,  especially  if  it  be  of 
small  volume,  at  the  moment  of  completing  the  section  of  the 
neck  of  the  bladder  and  the  prostate  gland.  The  urine  in  such 
a  case  may  drive  the  calculus  before  it,  which  may  thus  escape 
without  the  knowledge  of  the  operator,  and  be  lost  in  the  pool 
of  blood  and  water,  in  the  folds  of  the  blanket  or  upon  the  floor. 
Such  an  accident  might  not  only  subject  the  patient  to  needless 
sufiering,  from  long-continued  and   fruitless    attempts  to  find 


254  TEEATMEXT    OF    STONE    IX    THE    BLADDER. 

the  concretion,  but  also  seriously  compromise  tlic  character  of 
the  surgeon. 

10th.  The  greatest  embarrassment  which  the  lithotomist  has 
to  encounter  in  tlie  extraction  of  the  stone  arises  from  its  bulk. 
It  may  be  stated,  as  a  general  rule,  that  when  the  concretion 
weighs  three  to  four  ounces,  it  will  pass  tlie  wound  with  con- 
siderable diiSculty,andthe  impediment  will  be  much  augmented 
if  it  weighs  six  or  eight  ounces.     It  is  true,  a  much  larger  cal- 
culus has  sometimes  been  removed  successfully  ;  but,  in  most 
cases  of  this  description,  the  patient  has  had  either  a  very  narrow 
escape,  and  suflered  a  long  time,  perhaps  permanently,  from  the 
injury  sustained  by  the  bladder,  or  the  bladder  and  the  perineum,, 
in  the  extraction  of  the  foreign  body,  or  dies  from  exhaustion! 
during  the  operation,  or  a  short  time  after  from  the  effects  of' 
inflammation. 

When  the  calcu]us  is  of  unusual  magnitude,  the  extraction  \a\ 
to  be  accomplished  either  by  simply  enlarging  the  wound,  if  thie 
has  not  been  already  done,  to  the  utmost  permissible  limits,  oi 
by  incising  the  right  lobe  of  the  prostate  to  the  same  extent  as] 
the  left ;  or,  finally,  by  breaking  the  concretion,  and  removing  it] 
piecemeal.      Enlargement  of  the  wound   is  eflected  with   the! 
probe-pointed  bistoury,  carried  downwards  and  outwards  in  th( 
direction  of  the  original  incisions,  while  the  stone  is  held  firmlyj 
with  the  forceps.     The  perineum  being  thus  rendered  protuber- 
ant, the  resisting  parts  are  put   upon  the  stretch,  and  conse- 
quently yield  more  readily  before  the  knife.     The  right  lobe  of 
the  prostate  is  divided  in  the  same  manner,  and  in  the  same 
direction  as  the  left.     These  two  methods  may  almost  always  be 
resorted  to  with  a  reasonable  prospect  of  success,  when  thel 
weight  of  the  stone  does  not  exceed  three  or  four  ounces.     When! 
the  concretion  is  ver}'  bulky,  crushing,  with  the  forceps  repre-| 
sented  in  flg.  77,  will  generally  be  necessary. 

With  the  view  of  obtaining  more  room  for  extractino-  lars^el 
stones.  Sir  William  Fergusson*  practises  an  external  semilunarj 
incision  of  the  superiicial  structures  with  the  ordinary  lateral! 
section  of  the  prostate,  and  Mr.  Henry  Lee^  carries  an  incision] 
through  the  posterior  half  of  the  median  line  of  the  perineum] 

'  London  Lancet,  vol.  i.,  1868,  p.  1. 

2  Medical  Press  and  Circular,  Nov.  18,  18C8. 


LATERAL    LITHOTOMY. 


255 


to  two  or  three  lines  in  front  of  the  anus,  from  wliich  point  it  is 
extended  for  a  quarter  of  a  circle  around  the  front  and  left  side 
of  the  rectum,  the  operation  being  completed  as  in  the  lateral 
method.     The  object  of  these  procedures  is  to  provide  a  free 


Crushing  Forceps. 


external  opening  for  the  more  easy  extraction  of  the  concretion  ; 
but  as  they  do  not  provide  for  a  larger  opening  at  the  points 
where  the  difficulty  is  encountered,  I  cannot  see  that  they  possess 
any  advantages.  On  the  contrary,  they  retard  recovery  from 
the  great  length  of  time  required  for  the  closure  of  the  superfi- 
cial incisions. 

11th.  Embarrassment  of  a  serious,  if  not  an  insurmountable, 
character  may  arise  from  unusual  narrowness  of  the  outlet  of  the 
pelvis,  from  some  congenital  or  acquired  deformity.  In  rickety 
subjects,  the  opening  is  sometimes  reduced  to  a  mere  vertical 
slit.  In  such  a  case,  the  perineal  operation  of  lithotomy  would, 
of  course,  be  inadmissible. 

12th.  In  exceptional  instances,  circumstances  may  arise  which 
prevent  the  surgeon  from  operating  on  the  left  side  of  the  peri- 
neum, and  rendering  it  necessary  to  cut  on  the  right  side. 
Thus,  the  late  Prosessor  Pope,  of  St.  Louis,  was  obliged  to  resort 
to  this  course  on  account  of  a  vicious  position  of  the  thigh, 
caused  by  anchylosis  of  the  hip-joint ;  and  Zeiss  had  to  pursue 
a  similar  course  in  consequence  of  the  left  side  of  the  perineum 
being  occupied  by  a  congenitally  displaced  testicle. 

Lastly.  The  calculus  occasionally  coexists  with  calcareous 
incrustation  of  the  surface  of  the  bladder.  Such  a  complication 
will  necessarily  occasion  delay,  if  not  positive  embarrassment  in 
the  operation.  The  proper  procedure  is,  first,  to  extract  the 
calculus  in  the  usual  manner,  and  then  to  remove  the  calcareous 


256  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

matter  with  the   forceps,  scoop,  and    finger,  aided    with   the 
syringe. 

Accidents  a<:tending  Lateral  Lithotomy. — The  accidents  that 
are  most  liable  to  occur  during  and  after  the  lateral  operation, 
are  hemorrliage,  sinking,  retention  of  urine,  pelvic  cellulitis,  infil- 
tration of  urine,  phlebitis,  cystitis,  lesion  of  the  prostate  gland, 
peritonitis,  pyemia,  tetanus,  explosion  of  preexisting  disease, 
wound  and  sloughing  of  the  rectum,  incontinence  of  urine,  im- 
potence and  sterility,  perineal  fistule,  and  orchitis. 

a.  Hemorrhage. — One  of  the  most  serious  accidents  attend- 
ing lithotomy  is  hemorrhage.  This,  which  may  be  either  arte- 
rial or  venous,  ma}'  take  place  at  the  time  of  the  operation, 
before  the  completion,  perhaps,  of  the  incisions,  or  after  the 
incisions  have  been  made,  but  before  the  stone  is  extracted  ;  or 
it  may  not  happen  until  after  the  foreign  body  has  been  removed, 
and  the  patient  put  to  bed;  in  fact,  not  until  after  the  expiration 
of  several  hours  or  even  days.  In  the  former  case,  the  hemor- 
rhage is  said  to  be  primary ;  in  the  latter,  secondary.  The 
quantity  of  blood  lost  ma}-  be  small,  or  so  copious  as  to  induce 
severe  and  even  fatal  exhaustion. 

The  principal  sources  of  the  hemorrhage  in  this  operation  are 
the  artery  of  the  bulb  and  the  superficial  artery  of  the  perineum. 
In  old  subjects,  a  copious  flow  of  blood  occasionally  proceeds 
from  the  prostatic  plexus  of  veins.  The  pudic  artery,  in  its 
nonnal  coui-se,  can  hardly  be  wounded  posteriorly,  from  the 
manner  in  which  it  is  protected  by  the  tuberosity  and  ramus  of 
the  ischium ;  as  it  extends  forwards,  however,  into  the  anterior 
part  of  the  perineum,  it  becomes  more  exposed,  especially  where 
it  lies  between  the  layers  of  the  triangular  ligament,  and  is, 
therefore,  in  danger  of  being  injured.  This  accident  is  most 
liable  to  happen  wdien  the  prostate  is  divided  with  the  gorget, 
the  lithotome  cach^,  or  the  beaked  knife.  When  the  pudic 
artery  arises  directly  from  the  internal  iliac,  and  passes  forwards 
over  the  side  of  the  prostate,  on  its  way  towards  the  penis,  it  is 
hardly  possible  for  it  to  escape,  no  matter  how  the  operation  is 
performed. 

The  artery  of  the  bulb  is  one  of  the  largest  branches  of  the 
pudic,  and  is  apt,  when  divided,  to  bleed  profusely.  From  its 
deep  position,  and  the  readiness  with  which  it  retracts,  it  is 
alw^ays  secured  with  difiiculty.     It  is  best  avoided  by  entering 


LATERAL    LITHOTOMY.  257 

the  knife,  in  the  second  step  of  the  operation,  not  higher  than 
twelve  or  thirteen  lines  in  front  of  the  anus,  as  the  vessel  lies 
fourteen  lines  above  this  point.  If  the  incision  is  made  loAver 
down  in  the  perineum,  there  is  danger  of  cutting  into  the  groove 
of  the  staff  through  the  prostate  gland  instead  of  the  membra- 
nous portion  of  the  urethra  ;  a  circumstance  which  would  lead 
to  much  difficulty  in  extracting  the  stone.  When  the  artery 
arises  lower  down  than  natural,  its  division  is  almost  inevitable. 

A  tremendous  gush  of  blood  sometimes  proceeds  from  the 
transverse  perineal  artery,  which  is  occasionally  enormously 
enlarged,  even  in  verj'  young  subjects,  probably  in  consequence 
of  the  long-continued  irritation  kept  up  by  the  stone  in  the 
bladder.  The  bleeding,  in  this  case,  generally  follows  the  first 
incision,  and  should  be  immediately^  arrested  by  the  ligature. 

The  superficial  perineal  artery  is  rarel}^  cut ;  when  it  is,  the 
bleeding  is  generally  so  trifling  as  not  to  require  any  particular 
notice  on  the  part  of  the  operator.  It  is  only  when  the  vessel 
is  uncommonly  large,  or  when  it  retracts  within  the  opening  of 
the  fascia  through  which  it  emerges,  that  it  is  likely  to  become 
a  source  of  trouble.  In  either  case,  the  hemorrhage  may  be  so 
profuse  as  to  induce  the  belief  that  it  proceeds  from  a  wound  of 
the  pudic  artery. 

The  inferior  hemorrhoidal  artery,  the  posterior  branch  of  the 
pudic,  is  generally  of  small  size,  and  is  in  no  danger  of  being 
injured,  except  when  it  is  given  off  unusually  high  up,  and 
passes  almost  across  the  ischio-rectal  space  without  dividing. 
Should  such  an  anomaly  exist,  the  hemorrhage  might  be  quite 
free,  though  it  would  be  easily  enough  arrested,  unless  the  vessel 
is  cut  so  close  to  its  origin  as  to  retract  within  the  surrounding 
tissues,  or  its  coats  are  so  diseased  as  to  be  incapable  of  support- 
ing a  ligature. 

A  considerable  hemorrhage  occasionally  proceeds  from  the 
vesical  veins,  or  the  arteries  and  veins  of  the  prostate  gland.  In 
old  persons,  especially  in  such  as  have  labored  long  under  stone 
in  the  bladder,  stricture  of  the  urethra,  perineal  fistule,  irritation 
of  the  rectum,  or  disease  of  the  prostate,  these  vessels  are  exceed- 
ingly prone  to  varicose  enlargement,  forming  a  close  plexus, 
which  is  habitually  distended  with  black  blood.  The  connective 
tissue  in  which  tliis  plexus  is  imbedded,  is,  under  such  circum- 
stances, also  much  chano-ed  in  its  character,  beins;  not  onh' 
17 


2o8  TREAT.MENT    OF    STONE    IX    THE    BLADDER. 

increased  in  quantity,  but  likewise  considerably  indurated. 
Hence,  when  these  vessels  are  divided  they  are  unable  to  retract, 
or  l)ury  themselves  among;  the  surrounding  parts,  and  the  hemor- 
rhage, which  is  often  very  profuse,  the  blood  welling  out  simul-  i 
taneously  from  a  great  number  of  points,  can  only  be  arrested, 
by  protracted  compression,  aided  by  cold  applications. 

On  the  whole,  it  is  exceedingly  probable  that,  in  very  many 
cases,  if  not  in  a  majority,  in  which  the  hemorrhage  is  at  all 
copious,  it  proceeds  from  an  anomalous  arrangement  of  the  peri- 
neal arteries,  which  it  is  beyond  the  power  of  the  surgeon  to 
avoid. 

]Much  difficulty  is  often  experienced  in  ascertaining  whence 
the  blood  issues.  When  the  transverse  perineal  artery  is 
divided,  its  source  is  usually  sufficienth'  oljvious,  from  the  super- 
ficial situation  of  the  vessel ;  but  when  the  pudic  artery,  or  the 
artery  of  the  bulb,  is  cut,  it  is  no  easy  matter  frequently  to 
decide  this  important  question.  Nothing,  in  such  a  case,  short 
of  the  most  thorough  examination  can  enable  us  to  detect  the 
bleeding  orilice.  This  examination  should  be  conducted  witli 
the  fingers,  assisted  by  a  sponge  mop,  and  a  small  pair  of  fenes- 
trated forceps,  for  separating  the  deep  portion  of  the  wound. 

The  seat  of  the  hemorrhage  will  often  enable  us  to  determine 
its  source.  Thus,  when  it  proceeds  from  the  artery  of  the  bulb, 
the  blood  issues  from  the  upper  angle  of  the  wound  ;  from  the 
lower  angle,  when  it  is  furnished  by  the  hemorrhoidal;  and  from 
the  external  part  of  the  wound,  when  it  comes  from  the  pudic, 
or  superficial  perineal.  When  the  hemorrhage  is  seated  very 
deeply,  the  probability  is  that  it  proceeds  from  the  vesical  plexus, 
from  some  of  the  vessels  of  the  prostate  gland,  or  from  an  irregular 
distribution  of  the  pudic.  When  the  hemorrhage  arises  from 
the  injury,  division,  or  laceration  of  a  papillary  tumor  of  the 
bladder,  its  source  will  usually  be  sufiiciently  indicated  by  the 
difficulty  or  peculiarity  attending  the  operation,  and  by  the 
absence  of  hemorrhage  from  the  perineal  vessels. 

Serious,  if  not  fatal,  bleeding  may  arise  from  the  hemorrhagic 
diathesis.  The  blood,  in  this  variety  of  hemorrhage,  generally 
proceeds  from  numerous  points,  oozing  from  the  divided  parts 
as  from  the  pores  of  a  sponge.  Should  a  patient,  affected  with 
this  diathesis,  be  cut  for  stone,  he  would  proljahly  bleed  to  death  ; 
for  no  care  which  the  surgeon  could  employ  after  the  operation 


LATERAL    LITHOTOMY. 


259 


Fi£[.  79. 


would  be  likely  to  save  liim.  It  should,  therefore,  always  be  the 
duty  of  every  one  to  inquire  into  this  circumstance  before  he 
ventures  u[)on  the  use  of  the  knife. 

However  the  hemorrhage  may  be  induced,  or  from  whatever 
source  it  ma}-  originate,  it  is  to  be  borne  in  mind  that  the  blood 
may  escape  only  partiall}',  or  per- 
haps not  at  all,  at  the  wound,  but 
that  it  passes  inwards  into  the 
bladder,  where  it  is  either  retained, 
or  expelled  from  time  to  time  in 
thick  clots.  The  organ,  under 
these  circumstances,  will  form  a 
hard,  solid  tumor,  which  is  more  or 
less  tender  on  pressure,  and  which 
may  mount  as  high  up  as  the  um- 
bilicus. The  expulsion  of  the  clots 
is  attended  with  violent  spasm  and 
tenesmus,  bearing  a  close  resem- 
blance to  labor  pains. 

To  arrest  the  hemorrhage,  in  all 
cases  where  the  artery  is  within 
reach,  the  ligature  should  be  em- 
ployed in  preference  to  any  other 
expedient.  The  vessel  should  be 
seized  with  the  forceps,  tenaculum, 
or  needle,  and  secured  in  the  usual 
manner.  When  the  artery  of  the 
bulb  is  cut,  it  may  be  drawn  for- 
wards by  means  of  a  pair  of  very 
slender  polypus  forceps,  which 
answer  the  purpose  much  better 
than  the  common  instrument,  or 
the  tenaculum,  which  permits  the 
blood  to  escape  by  its  sides,  so  as 
to  obscure  the  bleeding  orifice,  and 
interfere  with  the  application  of 
the  ligature.  The  pudic  arterj^,  owing  to  its  deep  situation,  is 
best  secured  with  Physick's  forceps,  represented  in  the  annexed 
drawing,  tig.  78.  It  is  an  admirable  instrument,  and  should 
find  a  place  in  every  lithotomy  case. 


Physick's    Forceps. 


Canula  for  Plug- 
ging the  Wound 
iL  Lilhotonjy. 


260 


TREATMENT  OF  STONE  IN  THE  BLADDER, 


Compression,  which  maybe  resorted  to  in  all  cases  where  it  is 
impossible  to  use  the  ligature,  ma}'  be  made  with  the  finger,  a 
tam[)on,  a  canula,  or  a  pair  of  forceps.  The  former  of  these 
methods  was  much  employed  by  Pouteau,  who  sometimes  main- 
tained the  pressure  for  hours  together,  by  a  relay  of  assistants. 
The  practice  might  be  useful  in  some  cases,  as  when  the  other 
means  fail,  but  it  is  too  inconvenient  and  fatiguing,  both  to  the 
patient  and  the  surgeon,  to  be  resorted  to  on  slight  occasions. 

A  more  eligible  mode  of  making  compression  is  by  means  of 
a  canula,  surrounded  with  a  chemise.  The  canula,  represented 
in  fig.  79,  and  consisting  of  silver,  or  gum-elastic,  three  inches 
and  a  half  long,  by  four  lines  in  diameter,  open  at  the  vesical 
extremity,  and  provided  with  two  large  eyes,  is  inserted  into  the 
bladder,  previously  emptied  of  clots,  when  the  chemise  is  tighth* 
plugged  with  charpie  or  cotton.  The  instrument  is  then  secured 
by  means  of  pieces  of  tape  to  a  double-T  bandage,  and  answers 
the  twofold  purpose  of  conducting  off  the  urine,  and  compressing 
the  bleeding  vessels.  It  should  be  retained  for  four  or  five  days, 
or  until  there  is  reason  to  believe  that  all  danger  of  hemorrhage 
is  over.  When  no  canula  is  at  hand,  and  the  case 
is  urgent,  a  female  catheter,  a  piece  of  reed,  or  the 
spout  of  a  tin  coft'ee-pot,  may  be  used  as  a  substitute. 
This  mode  of  compression  is  particularly  applicable 
wlien  the  bleeding  proceeds  from  the  prostatic 
plexus  of  veins,  or  when  the  blood  oozes  from 
numerous  points. 

The  compression  may  be  effected,  in  the  third 
place,  with  a  common  tent,  or  a  tampon  of  sponge, 
charpie,  or  soft  linen ;  but,  in  this  case,  it  is  necessary 
to  keep  a  catheter  in  the  urethra  for  carrying  oft'  the 
urine.  In  this  variety  of  compression,  as  well  as  in 
the  preceding,  the  deep  portion  of  the  wound  must 
Ijc  plugged  first,  dossil  being  piled  upon  dossil  until 
the  whole  is  filled  up.  A  soft  compress  is  then 
applied  to  the  perineum,  and  the  whole  confined  by 
a   T   bandage.     In   obstinate   cases  of  deep-seated 

Arterial  i  i  i  i  x 

Compressor.       vcuous  hemorrhage,  the  compresses  may    be  satu- 
rated with  styptic  solutions,  or  a  sponge  wet  with 
a  saturated  solution  of  Monsel's  salt  will  be  found  useful,  as  I 
know  from  personal  experience. 


Fia;.  80. 


LATERAL    LITHOTOMY.  261 

Lastly,  when  the  bleeding  vessel  is  situated  very  far  back,  it 
may  be  grasped  by  the  delicate,  slender  forceps,  represented  in 
fig.  80,  which  I  devised  many  years  ago,  the  blades  being  perma- 
nently retained,  by  unscrewing  its  handle,  until  all  danger  from 
hemorrhage  is  over. 

Although  I  have  spoken  here  of  compression  by  plugging  the 
wound,  and  pointed  out  the  circumstances  in  which  it  is  appli- 
cable, I  must  confess  I  have  no  partiality  for  it.  On  the  contrary, 
I  should  alwa3's  resort  to  it  with  reluctance,  inasmuch  as  it  is 
not  only  attended  with  more  or  less  pain,  but  is  liable  to  lead  to 
undue  inflammation  both  of  the  perineum  and  the  bladder,  and 
may  even  be  productive  of  serious  consequences.  There  are 
cases,  however,  in  which  it  is  unavoidable,  and  in  which  no 
judicious  practitioner  would  hesitate  to  employ  it. 

Cold  applications,  in  the  form  of  irrigations,  may  be  used, 
in  many  cases,  with  benefit.  Made  directly  to  the  wound, 
the  perineum,  or  the  rectum,  they  have  a  tendency  to  induce 
contraction  of  the  bleeding  vessels,  to  allay  pain,  and  prevent 
inflammator}^  action;  The  water  should  be  directed  upon  the 
part,  in  a  continuous  but  gentle  stream,  from  a  fountain  sj^ringe, 
and  the  pelvis  should  be  so  situated  as  to  enable  it  to  run  into  a 
tub  at  the  side  of  the  bed.  A  piece  of  oil-cloth,  placed  under 
the  nates,  will  more  effectually  secure  this  object.  The  operation 
may,  if  necessary,  be  kept  up  several  hours  without  risk  of  injury. 
It  may  be  aided  by  cold  applications  to  the  hypogastric  region, 
groins,  and  inside  of  the  thighs  ;  by  strict  recumbency  ;  by  cool- 
ing, acidulated  drinks  ;  and  by  full  doses  of  opium,  which  should 
never  be  omitted,  as  they  constitute  an  important  part  in  the 
treatment  of  all  traumatic  hemorrhages.  When  the  bleeding 
depends  upon  the  hemorrhagic  diathesis,  our  chief  reliance  must 
be  upon  opium  and  acetate  of  lead,  opium  and  alum,  opium  and 
gallic  acid,  or  ergotine,  Avith  ice  and  some  one  of  these  salts  to 
the  wounded  parts. 

The  period,  after  the  operation,''at  which  secondary  hemorrhage 
sets  in,  varies  from  a  few  minutes  to  several  hours  or  days.  If 
it  does  not  come  on  within  the  first  ten  or  twelve  hours,  the 
prol)ability  will  be  strong  that  it  will  not  show  itself  at  all.  In 
general,  it  will  make  its  appearance  as  soon  as  reaction  is  estab- 
lished, or  the  patient  has  recovered  from  the  shock  of  the  opera- 
tion.    The  means  already  pointed  out  must  be  put  in  force;  the 


262  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

coagulated  blood  must  be  removed  with  the  fingei*s,  gcoop,  or 
s^'ringe ;  the  bleeding  vessel  must  be  exposed  and  tied ;  or,  if 
the  lijj-ature  is  inadmissible,  compression  or  irriijation  must  be 
resorted  to,  and  steadily  maintained  until  all  danger  is  past.         I 

i3.  Sinking. — Few  patients,  at  the  present  day,  perish  from 
the  shock  of  the  operation  of  lithotomy.  It  is,  however,  easy  to 
conceive  that  very  alarming,  if  not  fatal,  results  may  ensue  when 
the  operation  is  unusually  protracted,  when  great  violence  is  used 
in  extracting  the  stone,  accompanied  with  severe  contusion  or 
laceration  of  the  bladder  and  perineum,  or  when  there  has  been ' 
a  considerable  loss  of  blood.  Under  such  circumstances,  the 
shock  may  be  so  great  that  the  patient  may  die  upon  the  table, 
soon  after  he  is  put  to  bed,  or,  at  all  events,  during  the  first 
twenty-four  hours,  without,  perhaps,  any  attempt  at  reaction. 
In  former  times,  death  was  occasionally  produced  by  excessive 
pain,  operating  upon  a  nervous  and  debilitated  constitution  ; 
but  since  the  introduction  of  chloroform  and  other  anesthetic 
agents,  no  such  accident  has  occurred.  Persons  sometimes  perish 
from  sheer  fright  at  the  very  idea  of  a  severe  operation.  It  is 
related  of  Desault  that  he  one  day  lost  a  patient,  about  to  be 
lithotomized,  in  this  way.  The  man,  who  Avas  very  cowardly, 
fainted,  and  died,  under  the  impression  that  the  operation  was 
progressing,  when  the  illustrious  surgeon  Avas,  in  fact,  only  trac- 
ing the  line  of  the  intended  incision  upon  the  perineum  with 
his  finger. 

The  treatment  must  be  stimulating,  with  recumbency  and  free 
access  of  air.  When  reaction  begins,  the  patient  must  be  care- 
fully watched,  lest  over-excitement  take  place,  followed  by  exces- 
sive nervous  and  vascular  action. 

y.  Retention  of  Urine. — This  maj^  be  caused  by  inordinate 
tumefaction  of  the  wound  and  spasm  of  the  urethra  ;  or,  as  more 
frequently  happens,  by  the  closure  of  these  passages  by  coagu- 
lated blood.  In  the  former  case,  relief  is  aflforded  by  the 
catheter ;  in  the  latter,  by  clehring  away  the  blood  with  the 
finger  or  scoop,  and  preventing  further  hemorrhage. 

6.  Pelvic  Cellulitis. — An  acute,  rapidly  spreading  inflamma- 
tion of  the  perivesical  and  periprostatic  connective  and  vascular 
tissues,  known  as  pelvic  cellulitis,  is  a  fruitful  source  of  death  in 
adults.  It  occurs  generally  in  persons  of  unsound  health,  and  is 
occasioned  by  urinary  infiltration,  by  the  violence  sustained  by 


LATERAL    LITHOTOMY.  263 

tlio  (loop  parts  during  tlie  extraction  of  the  calculus,  bj  consti- 
tutional predisposition,  or  by  the  extension  of  erysipelas  from 
the  outer  wound.  Cellulitis  usually  supervenes  Avithin  the  iirst 
forty-eight  hours,  and  is  liable  to  lead  to  extensive  suppura- 
tion, the  formation  of  abscesses,  peritonitis,  or  septicemia.  It 
is  ushered  in  by  rigors  and  high  constitutional  disturbance,  and 
is  rapidly  followed  by  great  prostration  and  t^'phoid  symptoms. 
The  local  pathological  appearances  are  those  met  with  in  urinary 
infiltration,  and  the  treatment  is  conducted  upon  the  same 
general  principles  as  for  that  affection. 

a.  Urinary  Infiltration. — One  of  the  most  infrequent,  although 
one  of  the  most  dangerous  effects  of  lithotomy,  is  an  escape  of 
urine  into  the  connective  tissue  of  the  perineum,  or  of  the  peri- 
neum and  the  parts  immediately  around  the  neck  of  the  bladder. 
Its  occurrence  is  favored  by  too  free  a  division  of  the  prostate 
gland  ;  b}'  the  small  size  of  the  wound,  or  by  its  being  too  conical; 
by  the  early  and  inordinate  tumefaction  of  the  cut  surfaces; 
and,  above  all,  b}'  the  perforation  of  the  reflected  portion  of  the 
pelvic  fascia.  The  attack  usually  comes  on  within  a  short  time 
after  the  operation,  and  is  apt  to  run  its  course  with  frightful 
rapidity.  A  sense  of  weight,  heat,  and  smarting  at  the  neck  of 
the  bladder,  and  pa-in  in  the  hypogastric  region  behind  the  pubes, 
attended  with  symptoms  of  excessive  constitutional  irritation, 
denote  the  commencement  of  the  disease.  The  skin  is  hot  and 
dry,  the  pulse  weak  and  frequent,  the  tongue  parched  and  brown, 
the  wound  glazed  and  fetid,  and  the  urine  scanty  and  high  colored. 
The  prostration  rapidly  increases,  the  surface  becomes  covered 
with  a  cold,  clamni}^  sweat,  hiccup  sets  in,  the  abdomen  grows 
t^'mpanitic,  and  the  patient  dies  completely  exhausted,  usually 
in  three  or  four  days  from  the  invasion  of  the  malady.  On  dis- 
section, the  surfaces  of  the  wound,  the  intiltrated  parts,  the  neck 
of  the  bladder,  and  even  the  prostate  gland,  are  all  found  in  a 
highly  inflamed,  offensive,  and  sloughj'  condition.  Tlie  pelvic 
portion  of  the  peritoneum  is  frequently  red,  injected,  and  in- 
crusted  with  lymph. 

Little  can  be  done  to  arrest  the  i)rogress  of  this  affection  when 
once  established.  Depletion  b}'  the  lancet,  and  by  purgatives, 
is  wholly  inadmissible.  The  system  must  be  sustained  by  car- 
bonate of  ammonia,  quinine,  iron,  camphor,  and  capsicum,  in 
combination  with  tlie  liberal  use  of  brandy  and  opium.     Ano- 


26-4     TEEATMEXT  OF  STONE  IN  THE  BLADDER. 

(Ij'iics  are  indispensable  from  the  very  beginning.  Tlie  best 
topical  means  are  saturnine  and  opium  tbmentations,  medicated 
cataplasms,  injections  of  a  weak  solution  of  nitric  acid  or  chlo- 
rinated soda,  and  touching  the  whole  track  of  the  wound  as 
early  as  possible  with  nitrate  of  silver  or  the  tincture  of  iodine. 
When  the  infiltration  is  caused  by  the  small  size,  ill  shape,  or 
improper  direction  of  the  wound,  the  defect  must  be  remedied 
by  the  knife,  to  afford  a  free  outlet  for  the  urine.  Hot  fomenta-i 
tions  may  be  applied  to  the  hypogastric  region. 

C.  Phlebitis. — This    aflection   occasionally  occurs    after    this! 
operation.     It  is  most  frequently  met  with  in  elderly  subjects, 
affected  with  an  unusual  development  of  the  veins  of  the  neck 
of  the  bladder  and  the  prostate  gland.     The  disease    usually 
arises  within  the  first  four  or  five  days,  and  soon  spreads  through 
the  neighboring  connective  tissue,  assuming  a  diffused  erysipela- 
tous character^  and  terminating,  if  the  patient  survive  sufiiciently  j 
long,  in  purulent  infiltration.     The  treatment,  although  anti-j 
phlogistic,  is  conducted  cautiously,  and  with  due  regard  to  the 
constitution.     Cold  or  warm  applications  are  used  as  may  be, 
most  grateful  to  the  part  and  the  s^'stem;  iodine  is  applied  to  thei 
surface  around  the  wound,  especially  in  the  erysipelatous  form 
of  the  inflammation,  and  the  utmost  attention  is  paid  to  cleanli- 
ness.    If  gangrene  supervene,  the  wound  must  be  syringed  with] 
weak  solutions  of  nitric   acid,  tincture  of  myrrh,  chlorinate] 
of  soda,  or  chloral,  for  the  purpose  both  of  correcting  fetor,  andj 
instituting  a  more  healthful  action.     The  constitutional  treat- 
ment must  be  directed  upon  general  principles. 

The  phlebitis,  consequent   upon  this  operation,  occasionally! 
invades  the  extremities,  producing  symptoms  very  similar  to 
those  which  accompanj^  phlegmasia  dolons.     When  this  is  the 
case,  the  proper  local  remedies  will  be  leeches,  fomentations, 
iodine,  and  blisters,  followed  by  free  incisions  to  afford  vent  to] 
effused  and  pent-up  fluids.     The  sj-stem  must  be  supported  b}' 
anodynes  and  stimulants,  especiallj"  opium,  quinine,  and  brandy, 
administered  in  full  and  sustained  doses.     Venesection  is  gene- 
rally inadmissible,  if  not  decidedly  prejudicial,  and  tlie  use  of] 
mercury,  except  in  so  far  as  it  tends  to  correct  the  secretions, 
should  be  dispensed  Avith.     After  the  violence  of  the  inflamma- , 
tion  has  subsided,  the  limb  should  be  carefully  bandaged,  and 


LATERAL    LITHOTOMY.  265 

as  soon  as  the  patient  is  able  to  move  al30iit,  he  should  take 
gentle  exercise  in  the  open  air. 

7].  Cystitis. — Slight  inflammation  of  the  mucous  membrane  of 
the  bladder  is  one  of  the  most  common  complications  of  this 
operation,  supervening  within  the  first  few  days,  and  showing 
itself  by  a  frequent  desire  to  urinate,  with  more  or  less  spasm,  a 
sense  of  weight,  and  bearing-down  pains.  The  most  suitable 
remedies  are  hot  fomentations  to  the  hypogastrium  and  peri- 
neum, diluent  drinks,  and  full  doses  of  morphia.  When  the 
inflammation  is  urgent,  and  tends  to  extend  to  the  associated 
organs,  venesection  may  be  required. 

6.  Lesion  of  the  Prostate  Gland. — This  gland  may  be  seriously 
injured  in  the  operation,  either  by  the  knife,  the  finger,  the 
forceps,  or  the  calculus.  When  the  perineum  is  of  unusual 
depth,  it  may  be  difiicult,  especially  for  an  inexperienced  ope- 
rator, to  make  a  smooth  section  of  the  organ  ;  perhaps  the  knife 
slips  out  of  the  groove  of  the  staft",  and,  in  attempting  to  rein- 
sert it,  it  may  be  thrust  in  at  a  difterent  point.  Thus  the  part 
may  be  nicked,  as  it  were,  and  the  consequence  will  be  that  the 
wound  will  be  multiple  instead  of  being  simple,  as  it  always 
ought  to  be.  Again,  harm  may  be  done  with  the  finger,  in 
attempting  to  enlarge  the  wound  of  the  prostate  after  slight 
incision  has  been  practised.  In  general,  however,  there  is  little 
danger  from  this  course.  The  most  serious  mischief  is  usually 
inflicted  by  the  forceps,  the  blades  of  which,  instead  of  being 
expanded  over  the  stone,  embrace  a  portion  of  the  gland,  and 
either  bruise  it  severely,  or  tear  it  away  from  the  body.  The 
part  of  the  organ  most  liable  to  suffer  in  this  way  is  the  enlarged 
middle  lobe,  as  it  lies  behind  the  neck  of  the  bladder  in  the 
form  of  a  narrow  ridge,  or  nipple-shaped  prominence.  The 
error  can  generally  be  readily  detected  by  the  peculiar  feel  of 
the  tumor,  which  is  soft  and  compressible,  Avhile  the  calculus  is 
hard  and  unyieding.  Where  doubt  exists,  the  instrument 
should  be  carried  up  into  the  cavity  of  the  bladder  after  seizure 
has  been  effected,  or  the  finger  may  be  placed  in  contact  with 
the  body  as  it  lies  within  the  grasp  of  the  forceps.  In  the 
former  case,  the  instrument  will  refuse  to  ascend  if  it  has  hold 
of  the  prostate  gland,  and  in  the  latter  the  discrimination  is 
easily  determined  by  the  sense  of  touch. 

When  the  third  lobe  is  in  the  wav  of  the  stone,  it  should  be 


266  TEEATMEXT    OF    STOXE    IX    THE    BLADDER. 

depressed  with  tlio  finger;  or,  what  is  better,  the  bas-fond  of 
the  bladder  sboukl  be  elevated  through  the  rectum  ;  an  expe- 
dient which  will  bring  the  stone  on  a  level  with  the  jaws  of 
the  instrument,  and  enable  the  operator  to  seize  it  with  great 
facility. 

On  making  the  section  of  the  prostate,  it  sometimes  happens 
that  a  myomatous  fibroma  is  accidentally  enucleated  from  its 
bed,  and  brought  away  in  the  grasp  of  the  forceps  in  advance 
of  the  calculus.  I  have  met  with  this  occurrence  on  several 
occasions,  and  in  none  was  life  endangered,  although  in  all  the 
closure  of  the  wound  was  greatly  retarded.  In  a  case  of  this 
description,^  occurring  in  an  elderh'  subject,  post-mortem  inspec- 
tion, three  3'ears  and  a  half  subsequently,  disclosed  that  the 
cavity  left  by  the  removal  of  the  growth  had  progressivel}'  en- 
larged, until  a  large  pouch  had  formed,  which  had  increased 
the  difficulty  in  voiding  urine,  which  was  a  prominent  sym[)tora 
during  life. 

Wlien  the  prostate  has  been  much  contused,  or  lacerated, 
whether  unavoidably,  or  through  inadvertence,  the  best  practice 
is  to  cut  away  the  injured  part  with  a  pair  of  long,  curved, 
blunt-pointed  scissors,  such  as  surgeons  are  in  the  habit  of  using 
for  excising  the  uvula.  The  wound  is  thus  converted  into  a 
simple  one,  which  does  not  slough,  but  heals  by  the  granulating 
process. 

Where  the  stone  is  very  large,  the  prostate  may  sufll'er  exces- 
sive contusion  during  its  extraction,  followed  by  violent  iuHani- 
mation  and  even  sloughing.  In  such  a  case,  which  is  fortunately 
of  rare  occurrence,  our  chief  reliance  must  obviously  be  upon 
the  employment  of  antiphlogistic  remedies,  particularly  leeches 
and  ice  to  the  perineum,  in  the  earl}"  stage  of  the  treatment,  and, 
afterwards,  upon  fomentations  and  poultices. 

A  very  disagreeable  effect,  but  fortunately  a  very  rare  one,  of 
the  irregular  division  of  the  prostate  gland,  is  the  formation  of 
a  little  fiap,  tongue,  or  pedicle,  which,  after  the  healing  of  the 
wound,  may  fall,  like  a  valve,  against  the  orifice  of  the  urethra, 
and  thus  seriousl}-  impede  the  flow  of  urine.  The  part,  in  fact, 
produces  ver}"  much  the  same  trouble  as  hypertrophj'  of  the  mid- 
dle lobe  of  this  organ,  described  in  another  portion  of  the  Avork. 

'  Trans,  of  the  Path.  Soc.  of  Phihi.,  vol.  iv.  p.  U3. 


LATERAL    LITHOTOMY.  267 

Tf  the  existence  of  sucli  a  body  could,  in  any  way,  be  deter- 
mined during  life,  tlie  proper  remedy  would  be  crushino-,  or 
strangulation  by  means  of  a  silver  wire,  carried  into  the  bladder 
l)y  a  large  catheter.  Or,  these  expedients  failing,  relief  might 
be  attempted  b}'  lateral  cystotom}-. 

t.  Peritonitis. — Peritonitis  seldom  follows  the  operation  of 
lithotoni}',  whether  performed  at  the  perineum  or  above  the 
pubes.  It  is,  however,  more  frequent  in  the  latter  than  in  the 
former,  because  the  peritoneum  is  more  liable  to  be  wounded, 
and  because  there  is  also  more  danger  of  urinarj-  infiltration. 
In  the  perineal  operation,  it  is  exceedingly  rare  that  the  serous 
membrane  of  the  pelvis  is  injured  by  the  knife,  but  great  mischief 
is  occasionally  done  to  the  bladder  and  the  surrounding  parts 
by  rude  and  long- continued  attempts  at  extracting  the  foreign 
body.  From  this  cause.  Sir  Henry  Thompson  states  that  the 
aflection  is  more  common  in  children  than  in  adults,  and  that, 
in  them,  it  constitutes  the  chief  source  of  death.  My  own  ex- 
perience does  not  confirm  these  assertions,  since  I  have  met  with 
peritonitis  only  in  a  single  instance,  after  the  lateral  operation, 
in  140  cases,  and  the  subject  was  an  adult.  The  tables  of  Dr. 
Garden,  however,  sustain  the  statement  of  Sir  Henry  Thompson. 
Thus,  it  was  the  cause  of  death  in  108  out  of  a  total  of  824  cases 
operated  on  at  the  Sarahunpore  Dispensary,  52  per  cent,  having 
occurred  in  children,  and  21.66  per  cent,  in  adults  between  the 
thirtieth  and  seventy-eighth  year. 

The  treatment  must  be  prompt  and  vigorous.  Blood  should 
be  taked  from  the  arm,  or,  where  the  lancet  is  inadmissible,  by 
leeches  from  the  hj'pogastrium.  The  entire  belly  should  be 
kept  constantly  covered  with  hot  anodyne  fomentations,  renewed 
with  great  care ;  the  system  is  kept  fully  under  the  influence  of 
opium  ;  and  the  heart's  action  is  reduced  with  aconite  and  other 
depressants. 

X.  Pyemia. — Pyemia  is  most  liable  to  occur  in  broken-down 
persons,  from  violence  inflicted  during  the  extraction  of  the 
calculus.  It  is  probably  of  more  frequent  occurrence  than  is 
generally  supposed,  4  out  of  186  cases  of  lithotom}-  analyzed  by 
Mr.  Smith,  of  Leeds,  having  succumbed  to  it.  I  have  myself 
met  with  it  only  once,  the  patient  Ijoing  a  boy,  three  years  old, 
in  whom  the  wound  had  nearlj^  healed. 

The  disease  usually  sets  in  with  violent  rigors,  accompanied 


268  TUEATMEXT    OF    STONE    IN    THE    BLADDER. 

by  great  elevation  of  the  temperature  of  the  boch^,  and  followed 
by  copious  sweats  and  rapid  prostration,  and  death  within  the 
first  week.  The  treatment  is  most  unsatisfactory,  our  main 
reliance  being  upon  milk  punch,  large  doses  of  quinine,  and 
anodynes. 

X.  Tetanus. — Death  after  this  operation  has  been  known,  in 
some  instances,  to  be  caused  by  tetanus.  Of  such  an  event, 
which  must  be  very  rare,  especially  in  temperate  climates  and 
in  health}"  subjects,  I  have  no  personal  knowledge.  Should  an 
attack  be  threatened,  it  must  be  promptly  met  with  full  doses 
of  anodj'ues  and  antispasmodics,  and,  if  the  subject  be  much 
debilitated,  by  a  liberal  allowance  of  quinine  and  alcoholic 
stimulants.  When  much  suft'ering  is  present,  chloroform,  or 
nitrite  of  amyl,  will  be  found  to  be  valuable  adjuvants  in  con- 
trolling muscular  action. 

ix.  Explosion  of  Preexisting  Disease  and  Ischuria. — Stone,  as 
is  well  known,  frequently  coexists  with  other  diseases,  which, 
as  long  as  the  bladder  is  affected,  often  remain  in  a  state  of 
latency ;  or,  at  all  events,  make  but  little  progress  towards  a 
fatal  termination.  As  soon,  however,  as  the  vesical  irritation  is 
removed,  the}^  frequently  acquire  new  intensity,  and  proceed 
with  great  vigor  in  the  work  of  disorganization.  This  is  par- 
ticularly true  of  the  kidneys,  which  are  not  infrequently  in 
an  advanced  state  of  disease,  as  granular  contraction,  or  suppu-  I 
ration.  Under  these  circumstances,  death  may  ensue  within 
forty-eight  hours,  the  fatal  issue  being  preceded  by  rigors,  copious 
sweats,  intense  thirst,  vomiting,  pain  in  the  loins,  great  prostra- 
tion, ischuria,  delirium,  and  coma.  The  same  is  true  of  organic 
disease  of  the  ureters,  the  }>rostate  gland,  and  the  bladder  itself, 
but  not  to  the  same  degree.  Hence,  as  elsewhere  stated,  the 
rule  with  nearly  all  lithotomists  is  never  to  meddle  with  any 
case  in  which  there  is  reason  to  believe  that  there  is  serious  in- 
volvement of  any  portion  of  the  urinary  apparatus.  Unfortu- 
nately, however,  we  cannot  always  make  a  proper  application  of 
this  rule,  on  account  of  the  difficulty  of  forming  a  correct  diag- 
nosis. 

The  treatment  of  suppression  of  urine,  which  is  nearly  always 
promptly  fatal  from  uremic  poisoning,  consists  in  dry  cupping 
and  stimulating  liniments  to  the  loins,  and  the  exhibition  of 
diuretics  with  quinine  and  strychnia. 


LATERAL    LITHOTOMY.  269 

A  few  examples  have  occurred  in  Avlnch  death  has  been  caused 
by  apoplexy,  after  this  operation.  Tlie  event  is  most  liable  to 
happen  in  elderly  corpulent  subjects,  who,  having  long  suffered 
from  stone  in  the  Idadder,  have  led  an  indolent  life,  and  have, 
perhaps,  been  affected  with  ossification  of  the  cerebral  arteries. 
One  of  my  OAvn  patients,  a  man  upwards  of  seventy  years  of  age, 
died  from  apoplexy  of  the  brain  six  weeks  after  the  operation, 
from  the  effects  of  which  he  had,  apparently,  entirely  recovered. 

V.  Wound  of  the  Rectum. — This  accident  may  happen  in  any 
of  the  three  stages  of  lithotomy ;  but  it  is  not  likely  to  occur,  if 
the  bowel  be  depressed  over  towards  the  right  side  with  the  left 
index-finger,  as  the  knife  divides  the  deeper  seated  structures  of 
the  perineum  and  the  membranous  portion  of  the  urethra.  It  is 
only  by  neglecting  this  precaution,  or  omitting  to  lateralize  the 
knife  sufficiently  in  this  stage  of  the  proceeding,  that  the  rectum 
is  likely  to  suffer.  If  the  accident  do  occur,  the  opening  will 
commonly  be  found  to  be  small,  and  to  be  situated  immediately 
in  front  of  the  neck  of  the  bladder.  There  will  be  an  interchange 
between  the  parts  of  urine  and  feces,  the  quantity  of  which  varies 
in  different  cases,  and  the  discharge  of  which  may  continue  for 
an  indefinite  period.  In  general,  however,  it  soon  begins  to 
diminish,  and  ceases  altogether  in  fifteen  or  twenty  days,  or,  at 
furthest,  in  a  month.  In  children,  the  opening  sometimes  closes 
completely  in  less  than  a  week  ;  sometimes,  indeed,  by  the  first 
intention. 

An  accident  of  this  kind  is  in  general  more  disagreeable  than 
dangerous.  Unless  the  wound  is  very  large,  and  the  patient  in 
dilapidated  health,  nature,,  assisted  by  art,  is  almost  always  com- 
petent to  effect  a  cure.  The  treatment  consists  in  preventing 
the  bowels  from  acting,  except  every  third  or  fourth  day,  by 
means  of  anodynes,  in  washing  out  the  rectum  frecjuently  with 
cold  water,  in  permitting  none  but  the  most  bland  and  simple 
food,  in  the  constant  retention  of  a  soft  catheter,  in  touching  the 
opening  every  third  or  fourth  day  with  a  weak  solution  of  per- 
nitrate  of  mercury,  or  solid  nitrate  of  silver,  and  in  enjoining  a 
strict  observance  of  the  recumbent  posture.  The  suggestion  of 
Pouteau,  Desault,  and  others,  to  divide  the  parts  that  lie  between 
the  external  orifice  of  the  wound  and  the  opening  into  the  gut, 
cannot,  I  think,  be  too  much  deprecated.  If  the  practice  be  at 
all  justifiable,  under  any  circumstances,  it  is  only  when  the  track 


270  TREATMEXT    OF    STOXE    IX    THE    BLADDER. 

has  become  fistulous  or  remained  in  this  state  sufficiently  long 
to  induce  the  conviction  that  it  cannot  he  cured,  either  by  the 
eflbrts  of  nature,  or  the  means  just  pointed  out.  When  the 
operation  is  unavoidable,  it  should  be  conducted  upon  the  same 
principles  as  in  anal  fistule. 

t  Slouii'liino;  ot'the  Rectum. — Another  accident  which  occasion- 
ally  follows  the  operation  of  lithotomy  is  sloughing  of  the  rectum. 
It  is  most  liable  to  take  place  in  brokeu-down  subjects,  whose 
health  has  been  much  deteriorated  by  previous  sultcring,  or  who 
have  the  misfortune  to  be  cut  during  the  prevalence  of  erysipelas, 
or  within  the  walls  of  crowded  and  ill- ventilated  hospitals.  The 
immediate  cause  of  the  occurrence  is  probably  slight  infiltration 
of  urine  in  consequence  of  the  great  and  unnecessary  depth  of 
the  wound,  or  injury  done  to  the  recto-vesical  se[)tum  during  the 
extraction  of  the  calculus. 

The  efiect  of  such  an  accident,  leaving  out  of  the  question  the 
intiiimmatory  symptoms,  is  similar  to  that  of  a  rectal  fistule, 
caused  b}-  the  knife,  onlj- that  the  opening  of  communication  be- 
tween the  bladder  and  the  rectum  will  be  likely  to  be  much  larger, 
and,  consequently,  more  tardy  in  liealing.  Xo  definite  rules  can 
be  laid  down  respecting  the  treatment,  which  must  evidently  be 
regulated  by  the  circumstances  of  each  individual  case.  In 
general,  it  will  be  necessary  to  sup})ort  the  strength  b\^  a  carefully 
regulated  diet,  and  by  tonics,  especially  quinine,  wine,  and  l)randy. 
The  secretions  must  be  properly  attended  to,  and  the  parts  must 
be  kept  clean  by  the  frequent  injection  of  weak  solutions  of  soda, 
or  the  nitric  acid  lotion,  which  will,  at  the  same  time,  tend  to 
arrest  the  gangrene,  and  establish  healthy  action. 

0.  Incontinence  of  Urine. — Incontinence  of  urine,  consequent 
upon  perineal  lithotomy,  is  happily  infrequent  ;  but  it  is  more 
common  in  impubic  than  adult  subjects.  It  is  not  alwaj's  easy 
to  determine  how  this  accident  is  produced.  It  usually  arises 
from  injury  inflicted  upon  the  neck  of  the  bladder  during  the 
extraction  of  a  large  or  very  rough  calculus,  by  which  the  parts 
are  overstretched,  bruised,  or  lacerated.  The  loss  of  power  of 
the  sphincter  muscle  may  be  partial  or  complete.  In  most 
instances,  the  power  of  retaining  the  fluid  is  greater  in  the  recum- 
bent than  in  the  erect  or  semierect  posture,  because  less  pressure 
is  exerted  by  it  upon  the  neck  of  the  bladder  in  the  former  case 
than  in  the  latter.     The  affection  is  usually  accompanied  by  a 


LATERAL    LITHOTOMY.  271 

sense  of  uneasiness,  soreness,  or  burning  at  the  lower  part  of  the 
pelvis,  or  at  the  commencement  of  the  urethra. 

When  there  is  a  probability  that  incontinence  of  urine  will 
take  place,  every  eftbrt  should  be  made  to  prevent  it.  The 
patient  should  be  strictly  confined  to  his  bed,  a  warm  bath  sliould 
be  administered  once  a  day,  for  twenty-five  or  thirty  minutes  at 
a  time,  cold  water  should  be  frequently  thrown  into  the  rectum, 
and  free  use  should  be  made  of  demulcent  fluids.  When  the 
affection  is  fully  established,  it  will  be  necessary,  in  addition  to 
these  means,  to  leech  the  perineum  occasionally,  and  to  apply 
gentle  but  steady  pressure  upon  that  part  with  the  pad  of  a  T- 
truss,  or  an  instrument  constructed  upon  tlie  same  principles  as 
that  which  is  sometimes  worn  for  compressing  the  anus  in  pro- 
lapse of  the  rectum.  In  obstinate  cases,  cauterization  of  the 
neck  of  the  bladder  and  the  commencement  of  the  urethra  may 
be  tried  with  some  prospect  of  success.  Internally,  the  patient 
may  use  the  tincture  of  the  chloride  of  iron,  strychnia,  cantha- 
rides,  and  alkalies. 

rt.  Impotence  and  Sterility. — These  occurrences,  like  inconti- 
nence of  urine,  are  very  rare  after  lateral  lithotomy.  As  the 
operation  is  usually  performed,  the  prostate  gland  is  divided 
externally  to  the  seminal  ducts,  which  consequently  remain  intact. 
But  even  when  they  are  accidentally  wounded,  it  is  doubtful 
whether  any  ill  effects  will  result.  When  inf]^)Otence  follows  the 
operation,  it  is  almost  always  caused  by  violence  done  to  the 
seminal  ducts  or  their  orifices  during  the  extraction  of  the  stone, 
terminating  in  infiammation  and,  perhaps,  in  slight  gangrene. 
The  two  eflects  are  not  always  combined,  as  a  man  may  be  able 
to  copulate  but  not  procreate.  There  is  no  remedy  for  its  relief. 
Sometimes  the  patient  is  rendered  impotent  in  consequence  of 
the  semen  being  nearly  all  discharged  through  a  urethro-rectal 
fistule  instead  of  the  natural  passage. 

p.  Perineal  Fistule. — The  wound  made  in  lithotomy  generally 
heals  in  from  three  to  four  weeks  ;  but  sometimes  it  remains  open 
much  longer,  and  occasionally  it  does  not  close  at  all,  but  degene- 
rates into  a  fistule.  This  may  be  ownng  to  injury  done  to  the 
bladder  at  the  time  of  the  operation ;  or  it  may  be  caused,  more 
remotely,  by  ulceration  or  sloughing.  In  some  instances,  it  is 
dependent  upon  the  lodgment  of  sabulous  matter,  the  impaction 
of  a  fragment  of  stone,  or  the  constant  intromission  of  thick,  ropy 


272     TREATMENT  OF  STONE  IN  THE  BLADDER. 

mucus  Most  of  the  water  flows  through  the  natural  channel; 
only  a  small  quantity  escapes  by  the  fistule.  Sometimes  the 
perineal  opening  is  reduced  down  to  the  size  of  a  tliin  bristle, 
and  so  continues  for  many  years,  now  and  then  shedding  a  few 
drops  of  urine.  The  abnormal  track,  as  all  similar  passages  in 
other  parts  of  the  body,  becomes  gradually  lined  by  an  adventi- 
tious mucous  membrane.  The  existence  of  the  listule  is  deter- 
mined by  the  appearance  of  the  urine  at  the  external  opening, 
and  by  an  examination  with  a  probe. 

The  treatment  consists  in  drawing  oft'  the  urine  at  stated  in- 
tervals, and  in  cauterizing,  every  sixth  or  eighth  day,  the  neck 
of  the  bladder  with  nitrate  of  silver.  The  patient  should  be 
confined  to  his  back,  with  the  nates  resting  continually  higher 
than  the  other  parts  of  the  body,  in  order  that  the  urine  may  be 
prevented  from  coming  in  contact  with  the  inner  orifice  of  the 
fistule.  When  the  track  is  unusually  small,  and  the  perineum 
uncommonly  thin,  relief  may  sometimes  be  afforded  by  the  oc- 
casional introduction  of  a  heated  wire,  or  the  galvanic  cautery, 
or  a  probe  incrusted  with  nitrate  of  silver.  In  obstinate  cases, 
when  the  ordinary  remedies  have  proved  unavailing,  the  parts 
should  be  divided  with  the  knife,  as  in  the  first  instance, 
although  much  less  extensively.  All  foreign  substances,  ob- 
structing the  artificial  route,  must  of  course  be  removed  as  early 
as  possible. 

a.  Orchitis. — Inflammation  of  the  testicle  is  an  occasional 
result  of  lateral  lithotomy,  and  is  doubtless  due  to  injury  inflicted 
upon  the  ejaculatory  ducts  during  the  extraction  of  the  calculus. 
It  rarely  appears  before  the  end  of  the  second  week,  and  is  to  be 
met  by  the  measures  ordinarily  resorted  to  for  this  affection  from 
other  causes. 

After-treatment. — As  soon  as  the  stone  has  been  extracted, 
and  the  bleeding  arrested,  the  patient  is  untied,  cleansed,  and 
carried  to  his  bed,  which  should  always  be  properly  arranged 
before  the  operation.  It  should  be  provided  with  slats,  and  a 
cotton,  moss,  or  hair  mattress,  covered  with  a  sheet,  over  which 
is  spread  a  large  piece  of  soft  oil-cloth,  to  protect  the  bedding 
from  urine  and  blood.  Another  sheet  called  the  draw-sheet, 
folded  several  times,  and  arranged  so  as  to  make  the  middle  of 
it  correspond  with  the  buttocks,  is  placed  over  the  oil-cloth,  and 
serves  to  ward  oft"  pressure,  as  well  as  to  receive  the  secretions 


LATERAL    LITHOTOMY.  273 

as  they  flow  from  the  wound.     The  head  and  shoulders  should 
be  slightly  elevated  by  a  pillow. 

My  experience  is  that  it  matters  little,  if  any,  what  posture 
the  patient  assumes  after  he  has  been  put  to  bed.  I  usually, 
however,  request  him  to  lie 'on  his  right  side  for  the  first  five 
or  six  hours,  to  aiFord  the  lips  of  the  wound  an  opportunity  of 
becoming  glazed  with  lymph  before  he  is  obliged  to  urinate. 
At  the  end  of  this  period,  and,  indeed,  often  much  earlier,  I 
permit  him  to  rest  upon  his  back,  or  upon  either  side,  as  may 
be  most  agreeable  to  him.  Young  subjects,  unless  they  are  in- 
cessantly watched,  will  seldom  remain  in  the  same  posture 
beyond  a  few  minutes,  and  I  must  confess  I  have  yet  to  see  a 
case  in  which  any  detriment  resulted  from  this  source. 

It  is  equally  unnecessary,  in  my  judgment,  to  tie  the  patient's 
knees  together  after  the  operation  is  over,  and  he  has  been  put 
to  bed  ;  or  to  introduce  a  tube  into  the  bladder  by  the  wound, 
to  conduct  off  the  urine,  with  a  view,  as  it  is  alleged,  of  pre- 
venting infiltration  of  the  surrounding  connective  tissue.  This 
expedient  can  never  be  required  except  in  those  cases  in  which 
the  incisions  are  unusually  extensive. 

The  urine  sometimes  begins  to  flow  by  the  wound  in  a  few 
minutes  after  the  operation ;  but,  in  general,  little,  if  any,  passes 
for  the  first  four  or  five  hours.  It  then  usually  comes  away  in 
a  gush,  attended  frequently  with  severe  pain  and  spasm  of  the 
neck  of  the  bladder.  By  the  end  of  the  first  day,  the  edges  of 
the  wound  are  generally  so  much  swollen  that  the  urine  ceases 
to  flow  through  the  perineum,  and  takes  the  course  of  the  ure- 
thra. This,  however,  rarely  continues  beyond  twenty-four  or 
thirty-six  hours,  when  the  tumefaction  has  usually  so  far  sub- 
sided as  to  allow  the  fluid  to  resume  its  original  course.  The 
period  at  which  the  urine  begins  to  pass  oft' permanently  by  the 
urethra  varies  from  ten  to  fourteen  days.  Occasionally,  how- 
ever, I  have  known  it  to  happen  as  early  as  the  eighth  day  and 
as  late  as  the  twentieth.  The  change  in  the  direction  of  the 
fluid  is  always  attended  with  more  or  less  pain  at  the  neck  of 
the  bladder,  and  a  scalding,  smarting,  or  buring  sensation  in  the 
urethra  and  head  of  the  penis. 

The  treatment  after  the  operation  must  be  strictly  antiphlo- 
gistic.    The  patient  is  kept  quietly  in  bed,  and  all  excitement, 
both  bodily  and  mental,  is  sedulously  guarded  against.     The 
18 


274  TREATMENT    OF    STONE    IN    THE    BLADDEE. 

pain  consequent  upon  the  operation  is  often  extremely  severe, 
and  should  be  promptly  met  by  a  full  dose  of  morphia,  adminis- 
tered hypodermically. 

Demulcent  drinks  should  be  used  freely  throughout  the  treat- 
ment, especially  during  the  first  few  days.  They  not  only  allay 
thirst,  but,  what  is  of  great  importance,  they  dilute  the  urine, 
and  diminish  its  acrid  qualities,  thus  rendering  it  more  accept- 
able both  to  the  bladder  and  the  wound.  They  may  consist  of 
elm-bark  water,  flaxseed  tea,  or  gum  Arabic  Avater,  and  they 
may  be  simple,  or  comljined  with  nitrate  of  potassa,  bicarbonate 
of  soda,  or  dilute  nitric  acid,  according  to  the  i)articular  indica- 
tion of  the  c.ise. 

•  The  diet  must  be  light,  unirritant,  and  of  the  most  simple 
kind.  For  the  first  few  days,  the  jiatient  should  take  little  else 
than  panada,  thin  gruel,  weak  chicken  broth,  or  bread  and 
milk.  After  that  he  may  use  rice,  toast  and  tea,  crackers,  or  a 
small  quantit}'  of  mush  and  milk.  Xo  meat  or  vegetables  should 
be  permitted  under  five  or  six  days,  unless  the  patient  is  infirm 
or  there  is  marked  evidence  of  debility. 

In  all  cases,  I  make  it  a  rule  to  prevent  any  action  of  the 
bowels  for  the  first  three  days.  At  the  end  of  this  time,  I  gene- 
rally order  a  dose  of  castor  oil  or  Rochelle  salt,  assisted,  if  the 
purgative  is  tard}"  in  its  action,  by  an  enema  of  tepid  soapsuds. 
The  same,  or  other  means  may  be  resorted  to  afterwards  to  keep 
the  bowels  in  a  solu])le  condition.  If,  during  the  progress  of 
the  case,  the  patient's  tongue  becomes  coated,  and  his  appetite 
im[)aired;  or  if  his  general  health  suffers;  or  if  he  does  not 
improve  as  well  and  as  rapidly  as  he  ought ;  or,  finally,  if  the 
urinary  secretion  is  loaded  with  mucous  and  earthy  matter,  the 
best  remedy  he  can  use  is  a  dose  of  calomel,  which  often,  in  these 
circumstances,  acts  like  a  charm  in  promoting  recovery. 

The  draw-sheet  is  frequently  renewed,  and  every  possible 
attention  paid  to  cleanliness.  Sometimes  the  patient's  comfort 
is  greatly  promoted  by  a  soft  sponge,  or  an  old  napkin,  placed 
beneath  the  perineum,  and  arranged  so  as  not  to  compress  and 
obstruct  the  wound.  The  urine  is  thus  imbibed  as  fast  as  it 
flows  ofi',  and  the  consequence  is  a  less  frequent  necessity  for  a 
change  of  bed  and  body  clothes.  Excoriations  of  the  nates  and 
neighboring  parts  must  be  prevented  by  frequent  ablutions,  and 
the  application  of  benzoated  zinc  ointment;  and  the  scrotum 


LATERAL    LITHOTOMY.  275 

must  be  kept  out  of  the  way  of  the  wound  hy  a  suspensory 
bandage. 

During  the  progress  of  recovery,  it  sometimes  happens  that 
the  edges  of  the  wound  become  incrusted  with  phosphatic  mat- 
ter, forming  a  thin,  whitish  layer,  which  adheres  quite  firmly 
to  their  surface.  The  occurrence  is  not  productive  of  pain  ;  but, 
as  it  prevents  the  formation  of  healthy  granulations,  it  serves  to 
retard  the  reunion  of  the  parts,  and  should,  therefore,  be  promptly 
attended  to.  The  best  remedy  is  the  nitric  acid  lotion,  in  the 
proportion  of  about  four  drops  to  the  ounce  of  water,  applied  by 
means  of  a  folded  cloth.  When  the  incrustation  extends  far 
back,  the  fluid  may  be  injected  once  or  twice  daily  into  the 
bladder.  In  most  cases,  the  local  application  should  be  aided 
by  the  internal  exhibition  of  the  remedy. 

When  tlie  wound  is  tardy  in  healing,  or  has  contracted  to  a 
mere  orifice,  a  catheter  ought  to  be  permanently  retained  in  the 
bladder,  to  conduct  off  the  urine  through  the  natural  channel. 
The  walls  of  the  urethra  being  then  equally  distended,  and  the 
sides  of  the  wound  compressed,  a  cure  sometimes  follows  in  a 
few  days. 

The  wound  made  in  this  operation  occasionally  unites  by  the 
first  intention ;  but  such  an  event,  desirable  as  it  certainly  is, 
is  rarely  to  be  looked  for,  and  I  have  never  had  a  solitary  exam- 
ple among  my  own  cases.  Professor  Dudley,'  of  Lexington, 
witnessed  primary  union  eight  times  in  one  hundred  and  thirty- 
five  cases;  and  Mr.  Crichton,^  of  Dundee,  Scotland,  had  union 
by  the  first  intention  in  twenty-three  out  of  two  hundred  cases 
operated  on  by  him  ;  a  result  wdiich,  so  far  as  I  know,  is  with- 
out a  parallel. 

Statistics. — Of  2303  cases  of  lateral  lithotomy  in  the  hands  of 
American  surgeons,  156,  or  about  1  in  14J,  died.  Dudley  lost 
1  in  34|,  or  6  in  207  cases;  Mott,  1  in  23,  or  7  in  162  cases; 
Mettauer,  1  in  22f ,  or  4  in  91 ;  Kissam,  1  in  21f ,  or  3  in  65  ; 
Goldsmith,  1  in  19|-,  or  3  in  58  cases ;  and  N.  R.  Smith,  1  in  15, 
or  3  in  45.  My  own  practice,  embracing  140  cases,  shows  12 
deaths,  or  1  in  llf.  Of  66  impubic  subjects  all,  except  one, 
recovered,  while  of  74  operations  in  adolescents,  adults,  and 

'  Transylvania  Journal  of  Medicine  and  the  Associate  Sciences,  vol.  ix.  p. 
288,  1836. 
2  British  and  Foreign  Med.-Chir.  Review,  July,  1854,  p.  1.58,  Amcr.  ed. 


276 


TREATMENT  OF  STONE  IN  THE  BLADDER. 


old  persons,  11,  or  1  in  every  6f,  died.  In  foreign  practice 
the  results  are  not  so  favorable.  Thus,  of  2711  operations  in 
the  hands  of  Cheseldcn,  Martineau,  Liston,  B.  B.  Cooper, 
Southam,  Teale,  Fergusson,  Keith,  Norgate,  Crichton,  Grant, 
Cutclifte,  Curran,  Brett,  Raddock,  Pouteau,  Vericel,  Kern,  Zett, 
Wattmann,  Balassa,  and  Pollak,  278,  or  1  in  9|,  were  fatal. 
Martineau,  whose  success  has  always  been  considered  amongst 
the  most  brilliant  and  extraordinary  in  surgery,  lost  I  in  42,  or 
2  in  81  cases;  and  Pouteau,  1  in  40,  or  3  in  120  cases.  Prom 
the  combined  experience  of  American  and  European  operators, 
the  mortality  of  lateral  lithotomy  i  n  private  and  public  practice 
may  be  placed  at  1  in  12.92.  The  results  of  lateral  lithotomy 
in  hospital  practice  alone,  are,  however,  not  so  encouraging,  as  is 
shown  in  the  subjoined  table: — 

Table  showing  the  Results  q/"  5149  Cases  of  Lateral  Lithotomy  in 
Different  Hospitals. 


Locality. 

Number. 

Cures. 

Deaths. 

Proportion. 

Pennsylvania  Hospital 

105 

87 

18 

1  in    5.83 

Luneville  Hospital 

365 

333 

33 

1  in  11 

Hotel-Dieu,  Paris 

39 

30 

9 

lin    4.33 

La  Cliaritu,  Paris .... 

34 

19 

15 

1  in    3.36 

Hopital  des  Enfans,  Paris     . 

60 

51 

9 

1  in    6.66 

St.  Mary's,  Moscow 

411 

369 

43 

1  in    9.78 

Loretto  Hospital,  Naples 

553 

471 

83 

1  in    6.74 

Hospital  at  Canton 

147 

131 

16 

1  in    9.18 

Norfolk  and  Norwich  Hospital    . 

871 

755 

116 

1  in    7.50 

Bristol  Intirmary  .... 

354 

375 

79 

lin    4.48 

Leeds  Infirmary   .... 

197 

.    169 

38 

1  in    7.08 

Addenbrooke's  Hosp.,  Cambridge 

183 

170 

13 

1  in  14.07 

Radcliffe  Infirmary,  Oxford . 

110 

96 

14 

1  in    7.85 

Leicester  Infirmary 

90 

82 

8 

1  in  11.35 

Birmingham  Cxcneral  Hospital 

•102 

.       93 

10 

1  in  10.3 

Gny's  Hospital,  London 

330 

197 

33 

1  in    6.96 

St.  Thomas's  Hospital,  London   . 

200 

171 

39 

1  in    6.89 

University  College  Hosp.,  London 

90 

78 

12 

1  in    7.50 

Glasgow  Infirmary 

100 

86 

14 

1  in    7.14 

Futtehgnrh  Dispensary,  India 

84 

84 

0 

0in84 

Saharunpore  Dispensary,  India  . 

824 

716 

108 

1  in    7.63 

5149 

4461 

688 

1  in    7.48 

The  results  of  the  lateral  section  are,  as  was  before  stated, 
materially  affected  by  the  age  of  the  patient.  It  is  generally 
supposed  that  children  recover  most  readily  from  the  effects  of 
the  operation,  and  the  opinion,  although  not  without  exceptions, 
is,  in  the  main,  well  founded.     The  subjoined  tables  are  adduced 


LATERAL    LITHOTOMY. 


277 


in  illustration  of  tlie  subject.  The  first  afibrds  an  account  of 
Mr.  Cheselden's  cases,  and  is  the  more  interesting  and  valuable, 
as  it  exhibits,  in  bold  relief,  the  fruits  of  the  first  trials  of  the 
lateral  method,  as  practised  at  the  present  daj. 


Table 

of  Cheselden's 

Operations. 

Age 

Cases. 

Cures. 

Deaths. 

Proportion. 

From 

t  to  10       . 

105 

102 

3 

1   in  35 

10  to  20      . 

62 

58 

4 

1   in  15.5 

20  to  30      . 

12 

9 

3 

1   in    4 

30  to  40      . 

10 

8 

2 

1   in    5 

40  to  50      . 

10 

8 

2 

1   in    5 

no  to  60     . 

7 

3 

4 

1   in    1.75 

60  to  70      . 

5 

4 

1 

1   in    5 

70  to  80      . 

^ 

1 

1 
20 

1   in    2 

Total 

213 

193' 

1   in  10.65 

Table  of  704  Cases  at  the  Norfolk  arid  Norwich  Hospital. 


Age. 

Cases. 

Cures. 

Deaths. 

Proportion. 

From    1  to  10      . 

281 

262 

19 

1   in  14.79 

"      11  to  20      . 

lOG 

97 

9 

1   in  11.77 

"      21  to  30      . 

48 

43 

5 

1   in    9.6 

"     31  to  40      . 

48 

45 

3 

1    in  16 

"     41  to  50      . 

47 

37 

10 

1   in    4.7 

"      51  to  60      . 

96 

71 

25 

1   in    3.84 

"      61  to  70      . 

70 

50 

20 

1   in    3.5 

"      71  to  80      . 

8 

6 

2 

1   in    4 

Total 

704 

611 

93 

1   in    7.37 

Table  0/824  Cases  at  the  Saharunpore 

Dispensary.^ 

Age. 

Cases. 

Cures. 

Deaths. 

Proportion. 

From    1  to  10      . 

294 

272 

22 

1   in  13.36 

'      10  to  20      . 

123 

108 

15 

1   in    8.2 

'      20  to  30      . 

150 

136 

14 

1   in  10.7 

'      30  to  40      , 

102 

79 

23 

1  in    4.4 

'      40  to  50      . 

81 

68 

13 

1   in    6.2 

'      50  to  60      . 

55 

42 

13 

1   in    4.2 

'      60  to  70      . 

16 

10 

6 

1   in    2.6 

"      70  to  80      . 

3 

1 

3 

1   in    1.5 

Total 

824 

716 

108 

1    in    7.6 

'  The  calculi  in  three  of  these  cases  weighed,  respectively,  eight,  ten,  and 
twelve  ounces.  The  greatest  number  of  concretions  in  any  one  of  the  patients 
was  thirty-three. — Cheselden's  Anatomy,  p   333.     Boston,  1806. 

^  Dr.  Garden,  Indian  Annals,  Xo.  xxiii.,  1868. 


278 


TREATMENT  OF  STONE  IN  THE  BLADDEE. 


The  influence  of  asje  upon  the  result  is  well  shown  by  1827 
cases,  of  which  229  died,  derived  from  British  hospital  practice, 
and  tabulated  by  Sir  Henry  Thompson.  The  mortality  from  1 
to  11  years  w^as  1  in  17J  ;  from  12  to  16,1  in  9| ;  from  17  to  29, 
1  in  7|- ;  from  30  to  48,  1  in  7 J  ;  from  49  to  70,1  in  4|;  and  from 
71  to  81, 1  in  31 

Of  60  children  cut  by  M.  Guersant,  at  the  Hopital  des  Enfans, 
Paris,  9  died,  being  in  the  ratio  of  1  to  6f .  On  the  other  hand, 
of  56  children  operated  on  at  St.  Thomas's  Hospital,  London, 
only  one  perished ;  and  I  myself  have  lost  only  1  in  6Q  cases. 
Three-fourths  of  the  patients  lithotomized  by  Dr.  Dudley — 207 
in  number — were  under  15  years  of  age.  Of  ^Ir.  Martineau's 
84  cases,  26  were  from  1  to  10  years,  13  from  10  to  20,  9  from 
20  to  30,  7  from  30  to  40,  4  from  40  to  50,  and  25  from  50  to 
80.  The  loss  of  the  American  lithotomist  was  1  in  34|;  of  the 
English,  1  in  42. 

The  size  of  the  calculus  also  exercises  an  important  influence 
upon  the  results  of  the  operation  of  lithotomy,  not  only  when 
performed  according  to  the  lateral  method,  but  every  other. 
The  subjoined  table,  compiled  from  those  of  Mr.  Crosse  and  Dr. 
Garden,  gives  the  weight  of  the  calculus,  and  the  mortality, 
in  1327  cases  operated  on  at  the  Norwich  Hospital  and  the 
Saharunpore  Dispensary. 

Table  showing  the  31oriality  of  the  Lateral  Operation^  as  influenced 
by  the  Size  of  the  Calculus. 


Weight  in  ounces. 

Cases. 

Cures. 

Deaths. 

Proportion. 

1  ounce  and  under 

1  to  2  ounces        .... 

2  to  3        "           .... 

3  to  4        "           .... 

4  to  5 

5  to  6 

6  to  7        " 

969 

249 

68 

21 

11 

7 

2 

881 

211 

43 

!) 

5 

5 

88 

38 

25 

12 

6 

2 

9 

1   in  11.01 
1   in    6.55 
1    in    2.72 
1    in    1.75 
1   in    1.83 
1   in    3.5 

' 

1327          11.54           173 

1   in    7.67 

The  average  size  of  the  calculi  in  Dr.  Dudley's  cases,  as  I  am 
informed  by  Dr.  Bush,  was  less  than  that  of  a  pullet's  Qgg,  the 
weight  of  the  largest  being  9  ounces,  and  its  circumference  11| 
inches.     The  smallest  concretion  in  Martineau's  cases  w^eished 


LATERAL    LITHOTOMY.  279 

only  a  few  grains  ;  the  largest,  5|  ounces  ;  the  majorit}-  not  ex- 
ceeding 2  drachms. 

The  circumstances  which  tend  to  influence  the  results  of  the 
lateral— as,  indeed,  of  every  other  operation  of  lithotomy — are 
exceedingly  numerous  and  diversified  in  their  character ;  and 
are  worthy  of  profound  consideration.  The  most  important  of 
these  circuni'^tances  are  referable,  first,  to  the  skill  of  the  sur- 
geon ;  secondly,  to  the  manner  of  preparing  the  patient's  system  ; 
thirdly,  to  the  age  and  health  of  the  patient ;  fourthly,  to  the 
nature  and  volume  of  the  concretion,  and  its  situation  in  the 
bladder ;  and,  lastly,  to  the  selection  of  our  cases.  Children  are, 
all  other  things  being  equal,  better  subjects  for  the  operation 
than  adolescents,  adults,  and  aged  persons  ;  a  large  or  an  encj'sted 
calculus  will  be  more  likely  to  produce  mischief,  during  its  ex- 
traction, than  one  that  is  small,  or  free ;  and  a  sickly  individual, 
or  one  whose  constitution  has  been  impaired  by  protracted 
disease,  will  run  more  risk  than  a  healthy  one.  Then,  again,  a 
great  deal  apparently  depends  upon  sheer  luck.  Thus,  an  ope- 
rator will  occasionally  have  the  good  fortune  to  cut  twenty  or 
thirty  cases  in  succession,  without,  perhaps,  losing  a  single  one, 
and  he  is  disposed  to  congratulate  himself  upon  his  infallibility ; 
all  at  once,  however,  the  tables  are  turned  against  him,  and  the 
next  two  or  three  patients  slip  through  his  hands,  and  that,  too, 
perhaps,  without  any  appreciable  cause.  His  good  luck  has  for- 
saken him,  and,  b}^  the  time  he  reaches  his  fiftieth  case,  he  has 
the  mortification  to  see  that  his  victories,  like  those  of  a  skilful 
general,  have  not  been  achieved  without  a  certain  number  of 
victims. 

Tlie  preparation  of  the  system  must  also  exert  some  influence 
upon  the  result  of  the  operation.  How  fiir  this  should,  as  a 
general  rule,  be  carried,  is  a  point  which  cannot  be  easily  deter- 
mined. The  subject  is  one  upon  which  different  surgeons  will 
entertain  difterent  opinions.  I  am,  myself,  always  in  favor  of  a 
certain  amount  of  preparation  ;  but  I  do  not  think  that  it  should, 
in  ordinary  cases,  be  carried  very  far ;  for  the  very  fact  of  its 
employment  is  often  sufficient  to  inspire  the  patient  with  great 
dread  in  regard  to  his  ultimate  fate.  He  takes  it  for  granted 
that  an  operation  which  requires  so  much  preliminar}'  attention, 
must  necessaril}^  be  one  of  great  danger;  and  the  apprehension 
thus  engendered  is  well  calculated,  especially  if  he  be  at  all  timid, 


280  TREATMENT    OF    STOXE    IX    THE    BLADDER. 

to  unfit  him  for  the  approaching  ordeal.  ]Mr.  Brett,  of  Calcutta, 
who  cut  108  persons,  with  a  loss  of  only  7,  is  inclined  to  think 
tliat  his  success  was  chiefly  due  to  the  fact  that  he  always  ope- 
rated without  any  preparatory  treatment,  aided  hy  the  influence 
of  the  mild  -and  salubrious  climate  of  the  countr}',  and  the  simple 
habits  of  the  natives.  Mr.  Liston,  who  lost  16  patients  out  of 
115,  or  about  1  in  ll,  also  placed  very  little  reliance  upon  any 
measure  of  this  kind ;  whereas  Dr.  Dudley,  who  lost  1  in  34 J, 
always  considered  it  as  of  paramount  importance.  Mr.  Martincau 
always  kept  his  patients  a  week  in  the  house  before  they  were 
operated  on ;  he  regulated  their  diet  most  carefully,  but  gave 
them  very  little  medicine.  His  loss  in  84  cases  was  only  2,  or 
in  the  ratio  of  1  to  42.  It  is  to  be  lamented  that  we  have  no 
satisfactory  statistics  upon  a  subject  which  every  one  must  regard 
as  of  so  much  consequence. 

There  can  be  no  doubt  that  many  patients  are  lost  after  the 
operation,  even  although  this  may  have  been  executed  in  the  most 
dexterous  and  faultless  manner,  from  the  want  of  proper  care  on 
the  part  of  the  surgeon,  or  from  the  imprudence  and  intractable- 
ness  of  the  patients  themselves.  Children  and  young  persons 
generally  will  require  very  little  after-treatment  ;  but  elderly 
subjects  alwa3's  demand  the  greatest  vigilance.  The  proper  rule, 
however,  is  to  attend  to  all  alike  until  all  danger  from  theeftects 
of  the  operation  shall  have  passed  over. 

What  influence,  if  any,  season  exerts  upon  the  results  of  this 
operation  is  unknown.  The  only  statistics,  I  believe,  upon  this 
subject,  are  those  supplied  by  Mr.  Crosse,  and  these  are  on  so 
limited  a  scale  as  to  entitle  them  to  but  little  weight.  Of  100 
fatal  cases  of  the  lateral  section,  reported  by  this  writer,  6 
occurred  in  January,  3  in  February,  11  in  ^larch,  11  in  April, 
9  in  May,  9  in  June,  5  in  July,  6  in  August,  9  in  September,  9 
in  October,  13  in  Xovember,  and  9  in  December. 

Relapse. — When  it  is  considered  that  most  vesical  concretions 
have  their  origin  in  the  kidneys,  or,  at  all  events,  that  these 
organs  are  often  contemporaneously  affected,  it  is  not  surprising 
that  the  disease  should  occasionally  return  after  operation. 
What  number  of  cases  relapse  after  being  lithotomized,  is  a  point 
for  the  determination  of  which  we  have  no  positive  or  reliable 
data.     The  probability  is  that  the  proportion  varies  not  only  in 


LATERAL    LITHOTOMY.  281 

private  and  public  practice,  but  in  ditierent  institutions  and 
different  countries.  At  the  jSTorfolk  and  Norwich  Hospital  there 
were,  according  to  Mr.  C.  Williams,^  only  27  cases  of  relapse 
after  1015  operations,  or  1  in  37.58.  At  the  Luneville  Hospital, 
France,  the  register  shows  13  cases  of  relapse  after  1492  opera- 
tions, or  1  in  116.  At  La  Charitd,  Paris,  70  persons  were  cut 
for  stone  from  1806  to  1831,  and  in  6  of  these,  or  1  in  11,  the 
ojieration  was  performed  a  second  time.  Of  824  lateral  lithoto- 
mies at  the  Saharunpore  Dispensar}',^  only  6,  or  1  in  137,  were 
cut  a  second  time.  At  the  Hospital  of  Incurables,  jSTaples,  there 
were  10  relapses  in  401  cases.^  In  Bavaria,  according  to  the 
returns  received  by  Civiale,  the  proportion  of  relapses  is  as  1  to 
32 ;  in  Bohemia,  as  1  to  46  ;  in  Dalraatia,  as  1  to  53 ;  and  in 
Romania,  as  1  to  16.  From  the  general  table,  drawn  up  by  this 
distinguished  author  and  operator,  it  would  seem  that  the  number 
of  persons  affected  a  second  time  with  stone  in  the  bladder  after 
lithotomy,  is  very  small ;  for,  out  of  4446  cases,  only  42  relapsed, 
that  is,  1  in  105." 

I  have  referred  to  the  above  statistics,  not  on  account  of  any 
intrinsic  value  which  they  possess,  but  because  they  serve  to  show 
what  little  reliance  is  to  be  placed  upon  such  data.  If  we  take 
the  iN'orwich  tables  of  Mr.  Williams  we  shall  see  that  only  27 
persons  out  of  1015  suffered  from  relapse  after  having  been 
lithotomized.  iN'ow,  who  will  believe  that  this  is  a  true  repre- 
sentation of  the  facts  of  the  case?  Mr.  Williams  states  that 
these  individuals  were  cut  a  second  or  third  time,  but  he  does 
not  inform  us  liow  many  others  experienced  a  return  of  the  dis- 
ease without  having  submitted  to  a  second  operation.  It  is  per- 
fectly obvious  that  the  history  of  many  of  the  patients  must 
have  been  lost,  for  it  may  be  reasonably  inferred  that  compara- 
tively few  revisited  the  institution  in  which  they  had  been 
treated ;  and,  on  the  other  hand,  it  may  be  concluded,  that 
many  of  those  who  experienced  a  relapse  either  declined  further 
interference  altogether,  or  that,  if  they  sought  advice,  they  went 
to  other  operators.     Thus,  if  these  premises  be  correct,  it  follows, 

'  Holmes's  System  of  Surgery,  2d  ed.,  vol.  iv.  p.  1008. 

2  Dr.  Garden,  op.  cit.,  p.  56. 

3  Schmidt's  Jalirb.,  1834,  Bd.  4,  p.  215. 

••  Traite  de  1' Affection  Calculeuse,  p.  695.     Paris,  1838. 


282  TREATMEXT    OF    STONE    IX    THE    BLADDER. 

as  a  natural  consequence,  that  it  was  utterl}'  impossible  to  ascer- 
tain the  number  of  relapses  in  the  cases  to  Avhich  they  relate. 
The  table,  therefore,  like  everj^  similar  production  hitherto  [lub- 
lished,  is  of  little  practical  utility,  inasmuch  as  it  is  deficient  in 
its  details,  and,  therefore,  only  a  very  remote  approximation  to 
the  truth. 

Relapse  after  operation  is  no  doubt  greatly  influenced  by  the 
nature  of  the  calculous  diathesis.  There  are,  unfortunately,  no 
statistics  by  which  the  question  can  be  decided;  but  it  is,  I 
think,  safe  to  affirm,  that  persons  affected  with  phosphatic  cal- 
culi are  more  prone  to  suffer  a  second  and  even  a  third  time  than 
those  affected  with  lithic  concretions,  or  concretions  composed 
of  urate  of  ammonia  or  oxalate  of  lime.  Organic  disease  of  the 
kidneys  and  ureters,  the  bladder,  prostate  gland,  and  urethra, 
may  be  mentioned  as  a  predisposing  cause  of  relapse.  Derange- 
ment of  the  digestive  organs,  especiall}'  if  protracted,  and 
attended  with  much  flatulence  and  acidity,  exercises  a  similar 
influence.  Indeed,  whatever  has  a  tendency  to  disorder  the 
general  health,  and  depress  the  vital  powers,  will  be  likely  to 
promote  the  occurrence  of  the  malady,  and  should,  therefore, 
receive  the  closest  scrutiny,  and  the  promptest  attention.  Injury 
of  the  spine,  as  from  a  fall,  blow,  or  kick,  especially  if  followed 
l)y  paraplegia,  will,  unless  very  speedily  relieved,  be  almost  sure 
to  be  succeeded  by  relapse. 

The  period  at  Avhich  the  relapse  occurs  must,  of  course,  depend 
upon  circumstances,  the  nature  of  which  it  is  frequently  impos- 
sible even  to  conjecture,  much  less  to  explain.  Occasionally  it 
is  very  short ;  and,  on  the  other  hand,  a  number  of  months,  and 
even  years,  may  intervene,  the  general  health,  meanwhile,  being 
perhaps  little,  if  at  all,  impaired.  As  a  general  rule,  it  may  be 
assumed  that  the  phosphatic  and  amraoniaco-magnesian  calculi 
are  more  rapidly  reproduced  than  the  lithic  and  oxalic.  But 
to  this  exceptions  occasionally  occur.  Thus,  in  an  instance 
communicated  to  me  b}-  Dr.  J.  Dixon,  of  Alleghan}',  a  man, 
aged  sixty -nine,  from  whom  he  removed  two  large  calculi  of  this 
kind,  experienced  a  return  of  his  vesical  symptoms  at  the  end 
of  three  months.  He  had  labored  under  gravel  from  an  early 
})eriod,  and  made  a  very  rapid  recovery.  A  second  operation 
was  performed  a  year  after  the  first,  and  five  similar  calculi — 
two  as  large  as  the  previous  ones — were  extracted,     lie  again 


LATERAL    LITHOTOMY.  283 

made  a  ra})id  recovery,  and  lias  remained  free  from  urinary  dis- 
ease ever  since,  now  a  period  of  three  years. 

In  two  of  my  own  cases,  the  interval  between  the  operation 
and  the  recurrence  of  the  disease  was  very  short ;  in  one  it  did 
not  exceed  four  weeks.  When  this  happens,  the  vesical  affection 
is  always,  as  a  general  rule,  complicated  with  renal  disorder, 
resulting  in  the  formation  of  concretions,  which  gradually 
descend  into  the  bladder,  where  their  presence  is  speedily  fol- 
lowed by  a  reproduction  of  the  previous  symptoms.  This  cir- 
cumstance was  strikingly  evinced  in  the  instance  of  Alexander, 
from  whom  I.  extracted  two  calculi,  with  only  very  temporary 
relief,  and  whose  kidnej- s,  in  less  than  a  year  after  the  operation, 
were  literally  filled  with  calculous  matter ;  at  the  same  time 
that  the  bladder  contained  eleven  distinct  concretions,  from  the 
volume  of  a  millet  seed  to  that  of  a  small  filbert.  In  such  a 
case,  there  evidently  exists  a  calculous  diathesis,  which  no  treat- 
ment, whatever  may  be  its  character,  can  correct  or  arrest.  It 
is  worthy  of  notice  that  the  new  stone,  especially  when  rapidly 
formed,  is  usually  very  soft  and  fragile,  breaking  under  the 
gentlest  pressure  of  the  forceps. 

The  case  is  quite  different  when  the  relapse  is  occasioned  by 
an  imperfect  clearance  of  the  bladder.  The  accident,  fortunately 
infrequent,  has  happened  to  good  operators,  and  is  not  always 
avoidable,  especially  when  there  are  several  concretions,  of 
which  one  is  extremely  small;  or  when  there  is  only  one,  and 
a  spicule  or  fragment  breaks  oft",  and  hides  itself,  as  it  were, 
between  the  folds  of,  or  in  the  bas-fond  of  the  bladder.  In- 
jection of  the  viscus  with  a  large  syringe  and  a  full  stream  of 
water  is  the  best  guarantee  against  this  contingency.  Should 
recurrence  of  the  symptoms  take  place,  no  time  must  be  lost  in 
ascertaining  the  real  condition  of  the  bladder.  If  the  concretion 
is  small,  extrusion  is  promoted  by  dilatation  of  the  urethra  ;  if 
this  fail,  lithotomy  is  again  employed,  and  now,  if  possible,  with 
greater  care,  to  insure  future  immunity. 

The  best  mode  of  determining  the  existence  of  fragments  in 
the  bladder  after  the  cicatrization  of  the  wound  in  lithotomy, 
is,  undoubtedly,  the  introduction  of  the  sound.  The  instrument 
is,  of  course,  used  in  the  same  manner  as  under  ordinary  circum- 
stances, but  great  care  sliould  be  taken  that  the  organ  do  not 
contain  too  much  water,  otherwise  it  will  not  be  likely  to  hit 


284     TREATMENT  OF  STOXE  IN  THE  BLADDER. 

the  concretion,  or,  hitting  it,  to  elicit  anything  like  a  satis- 
factory sound.  It  is  well-known  that,  owing  to  the  retention 
of  fragments,  relapse  is  much  more  common  after  lithotrity  than 
after  lithotom3\ 

Repetition  of  the  Operation. — It  has  been  already  stated  that 
the  operation  of  lithotomy  may,  from  various  causes,  require  to 
be  repeated,  not  only  once,  but  perhaps  a  number  of  times ;  and 
not  only  so,  but,  perhaps,  in  pretty  rapid  succession.  Thus,  a 
case  occurred  to  Dupuytren  in  which  he  cut  twice  in  three  days. 
Sir  Astley  Cooper  operated  three  times  in  one  case,  and  his 
nephew,  Mr.  Bransby  Cooper,  also  upon  another  individual, 
within  the  space  of  four  years.  Dr.  Van  Buren  informs  me  that 
Dr.  jNIott  has,  on  three  occasions,  operated  a  second  time  on  the 
same  patient,  and  that  one  of  the  cases  had  a  fatal  issue.  Dr. 
Dudley,  out  of  two  hundred  and  seven  cases,  has  had  but  one, 
that  of  a  colored  boy  twelve  years  of  age,  in  which  he  performed 
a  second  operation.^  The  late  Dr.  Nathan  Smith,^  of  New 
Haven,  who  had  altogether  twenty-three  cases,  was  obliged  to 
cut  one  of  his  patients  three  times.  There  are  at  least  fourteen 
cases  on  record  in  which  the  patient  was  cut  four  times,  and 
four  cases  in  which  five  operations  were  performed.^ 

But  the  most  remarkable  instance  of  this  kind  upon  record 
is  that  reported  by  Mons.  Clever  de  Maldigny,  a  military  sur- 
geon, at  a  meeting  of  the  French  Institute,  in  May,  1827.*  In 
a  paper  on  lithotomy,  read  before  that  learned  body,  he  stated 
that  he  had  been  the  subject  of  stone  not  less  than  seven  times, 
and  that  he  had  six  times  undergone  the  lateral  operation, 
namcl}^,  at  the  age  of  six,  eight,  eighteen,  twenty,  twenty-two, 
and  twentj'-four  years.  The  sixth  time,  the  stone  was  situated 
at  the  neck  of  the  bladder,  and  the  patient  cut  himself,  a  glass 
being  placed  between  his  legs,  to  enable  him  to  direct  the  bis- 
toury in  the  course  of  the  cicatrice  of  the  previous  incisions. 
The  calculus  was  extracted  with  the  fingers.  In  his  seventh 
attack,  he  had  recourse  to  lithotrity,  which  was  successfully  per- 

'  Dr.  Bnsh,  MS.  letter  to  the  author. 

*  Medical  and  Surgical  Memoirs,  edited  by  N.  R.  Smith,  M.D.,  p.  244.  Bal- 
timore. 1831. 

3  Dr.  Piersig.  Beitriige  zur  Chir.  Path,  der  Handwerkzeuge.  vou  Dr.  Bruno 
Schmidt.     Leipzig,  I860,  p.  45. 

*  Revue  Medicale,  June,  1827  ;  Lou  loa  Lancet,  vol.  xii.  p.  006. 


BILATERAL    LITHOTOMY.  285 

formed  at  four  sittings,  by  Dr.  Civiule.     Subsequently,  Clever 
was  operated  upon  for  stone  the  eighth  tinie.^ 

When  the  perineum  has  been  repeatedly  cut  for  the  removal 
of  stone  from  the  bladder,  the  resulting  cicatrice  is  apt  to  be- 
come preternaturally  dense,  and  to  offer  more  resistance  to  the 
knife  than  the  healthy  tissues.  The  part  occasionally  remains 
tender  for  a  long  time,  and  in  some  instances  it  has  been  known 
to  be  the  seat  of  neuralgic  pain.  A  second  operation  has  often 
permanently  cured  a  small  but  intractable  fistule  left  by  the 
first. 

Art.  II.— bilateral  LITHOTOMY. 

The  merit  of  devising  this  operation  is  usually  ascribed  to 
Celsus,  though  it  more  probably  belongs  to  Le  Dran.  Its  ad- 
vantages have  been  prominently  set  forth  in  modern  times  by 
Chaussier,  Beclard,  and  Dupuytren,  the  latter  of  wdiom  per- 
formed it  successfully  in  1824,  and  who  may  be  said  to  have 
regularized  and  perfected  it.  In  this  operation,  the  perineum 
and  the  prostate  gland  are  divided  on  both  sides,  with  less  risk,  it 
is  asserted,  than  in  the  ordinary  method,  of  wounding  the  pelvic 
fascia  and  the  surrounding  plexus  of  veins.  It  is  contended,  more- 
over, by  the  advocates  of  this  plan,  first,  that  it  is  better  adapted 
to  the  removal  of  large  calculi ;  secondly,  that  it  is  applicable  to 
all  ages  and  to  both  sexes ;  thirdly,  that  it  is  singularly  easy  of 
execution ;  and,  fourthly,  that  it  secures  the  rectum,  the  bulb, 
the  perineal  arteries,  and  the  seminal  ducts,  from  liability  to  in- 
jury. That  some  of  these  advantages  are  exaggerated  is  suffi- 
ciently evident.  Thus,  as  it  respects  hemorrhage,  it  is  perfectly 
certain  that  several  patients  have  perished  from  it.  It  is  also 
certain  that  it  is  not  easier  of  execution  than  the  lateral  section, 
which  is  often  performed  in  an  almost  incredibly  short  time ; 
nor  is  it  any  better  adapted  to  persons  of  difi'erent  ages.  If  it 
possess  any  advantages  at  all  over  the  ordinary  method,  it  must 
be  on  the  ground  that  it  afi:brds  a  larger  opening  for  the  passage 
of  the  foreign  body,  and  that  it  is  attended  with  less  danger  to 
the  rectum  and  the  seminal  ducts.  But  even  of  these  the  former 
!  is,  in  great  degree,  counterbalanced  by  the  modern  metliod  of 

"  Loud.  Med.  aud  Surg.  Jouru.,  New  Series,  vol.  v.  p.  204. 


286 


TREATMENT  OF  STOXE  IX  THE  BLADDER. 


Fiir.  81. 


dividino;  the  right  lohe  of  the  prostate,  if  the  wound  in  the  left 
be  found  insufficient  for  the  extraction  of  the  calculus.  In 
reality,  then,  the  bilateral  section  has  but  one  advantage  over 
the  lateral,  namely,  the  greater  immunity  which  it  affords  to 
the  bowel  and  the  seminal  ducts. 

The  bilateral  operation  requires  the  same  preliminary  measures 
as  tliQ  other  method.  The  patient  is  placed  in  the  same  position, 
the  limbs  and  the  staff  are  held  in  the  same  manner,  and  the 
surgeon  occupies  the  same  situation.  The  incisions  through  the 
perineum  as  far  as  the  groove  of  the  staff,  are 
executed  with  an  ordinary  scalpel,  and  the  pros- 
tate is  divided  with  a  double  lithotome  cache,  re- 
presented in  fig.  81,  a  narrow  knife,  or  a  probe- 
pointed  bistoury,  according  to  the  whim,  fancy, 
or  caprice  of  the  lithotomist. 

A  staff  with  a  central  groove  having  been 
introduced  into  the  bladder,  a  semilunar  incision 
is  carried  across  the  perineum,  beginning  on  the 
right  side  midway  between  the  tuberosity  of  the 
ischium  and  the  margin  of  the  anus,  but  a  little 

Ficr.  83. 


Double  Lithotome 
Cache. 


Bilateral  Lithotomy. 


nearer  the  former  than  the  latter,  and  terminating  at  the  corre- 
sponding point  of  the  opposite  side,  when  it  assumes  the  form 


BILATERAL    LITHOTOMY.  287 

seen  in  fig.  82.  The  concavity  of  the  cut  is  directed  downwards, 
and  its  centre,  situated  at  the  raphe  of  the  perineum,  is  about 
nine  lines  above  the  anus.  In  tliis  direction  are  divided  suc- 
cessively the  skin,  the  connective  tissue,  and  the  superficial 
fascia,  together  with  a  few  of  the  anterior  fibres  of  the  external 
sphincter  muscle.  The  end  of  the  left  forefinger  is  now  placed 
in  the  bottom  of  the  wound,  just  as  in  the  ordinary  procedure, 
the  staft"  sought,  and  the  membranous  [lortion  of  the  urethra 
laid  open  to  the  extent  of  four  lines.  The  nail  of  the  finger  is 
then  applied  to  the  staff",  to  serve  as  a  guide  to  the  lithotome, 
the  beak  of  which  is  next  inserted  into  the  groove  of  the  instru- 
ment, with  its  concavity  looking  upwards.  Taking  care,  by 
moving  the  lithotome  several  times  forwards  and  backwards, 
that  it  is  securely  lodged  in  the  groove,  the  surgeon  seizes  the 
handle  of  the  staft",  and  depresses  it  nearly  to  a  level  with  the 
abdomen,  at  the  same  time  that  he  lowers  the  lithotome,  and 
pushes  it  onward  into  the  bladder.  As  soon  as  the  instrument 
has  reached  the  bladder,  its  point  is  disengaged  from  the  staff", 
and  brought  in  contact  with  the  stone,  when  the  staff"  is  imme- 
diately removed.  The  lithotome  is  then  reversed  with  its  con- 
cavity towards  the  rectum,  and  while  it  is  in  this  position  it  is 
withdrawn,  its  blades  being  expanded  by  pressing  on  their 
springs.  In  this  manner,  it  cuts  its  way  out,  slowly  and 
steadily,  dividing  in  its  retrograde  course  the  sides  of  the  pros- 
tate, in  a  direction  obliquely  downwards  and  outwards,  as  in 
the  ordinary  section.  Tlie  finger  now  takes  the  place  of  the 
instrument,  the  situation  of  the  stone  is  ascertained,  the  for- 
ceps are  introduced,  and  extraction  is  eff'ected  in  the  usual 
manner. 

Various  modifications  of  the  bilateral  operation  have  been 
made  by  different  operators,  but  it  is  questionable  whether  they 
possess  any  practical  value.  The  first,  practised  by  Civiale  from 
1829  to  the  date  of  his  death,  combines  a  median  section  of  the 
soft  parts  down  to  the  apex  of  the  prostate,  with  a  bilateral  sec- 
tion of  the  gland  in  a  transverse  direction  with  a  straight  double 
lithotome,  the  extent  of  this  latter  incision  being  less  than  in 
Dupuytren's  procedure.  Sir  AVilliam  Fergusson,  in  1843,  with 
a  view  to  furnish  a  larger  external  wound,  united  the  ordinary 
median  incision  with  the  crescentic  incision  above  the  anus,  so 


288 


TREATMENT  OF  STOXE  IN  THE  BLADDER. 


Fig.  83.  that  the  superficial  wound  resembled  an  inverted 

Y,  as  shown  in  fig.  83.  Finally,  Xelaton'  performed 
a  prerectal  operation,  by  a  transverse  incision  two 
inches  long,  carried  across  the  perineum  two-fifths 
of  an  inch  in  front  of  the  anus,  or  so  close  to  the 
bowel,  in  order  to  avoid  the  bulb,  that  it  may  be^ 
viewed  as  a  careful  dissection  of  the  rectum  froi 
the  surrounding  parts,  the  operation  being  com-j 
pleted  with  the  double  lithotome.  Of  all  these  so-called  im-^ 
provements,  the  last  is  by  far  the  least  desirable,  as  it  subjects 
the  patient  to  longer  confinement  and  the  liability  to  the  occurs 
rence  of  urinary  tistule. 

The  bilateral  operation  of  lithotomy  has  never  had  any  dis- 
tinguished advocates  in  Great  Britain,  and  its  principal  supportersj 
in  this  country,  at  the  present  day,  are  Professor  Eve,  of  Xash- 
ville,  and  Professor  Hughes,  of  Keokuk. 

Of  429  cases  in  the  hands  of  American  surgeons,  407  recovered, 
and  22,  or  1  in  19.09,  died.     Of  22  medio-bilateral  operations,  all| 
were  cured.     If  to  these  cases  are  added  85,  with  19  deaths,  tabu- 
lated by  Dupuytren,  we  shall  have  an  aggregate  of  536  cases,] 
with  41  deaths,  or  a  loss  of  1  in  13.07. 


Art.  III.— median  LITHOTOMY. 

Median  lithotomy  consists  in  cutting  through  the  superficial] 
structures  and  membranous  urethra  in  the  middle  line  of  the 
perineum,  and  dilating  the  prostate  and  neck  of  the  bladder  toj 
an  extent  sufiicient  for  the  easy  extraction  of  the  calculus. 
Originally  suggested,  in  1808,  by  Manzoui,  of  Verona,  and  sub-l 
sequently  adopted  by  Rizzoli  and  De  Borsa,  lithectasy,  as  this! 
procedure  may  be  termed,  has  more  recently  been  warmly  advo-| 
cated  by  Mr.  George  Allarton,  of  England,  by  Professor  Reyer,of| 
Cairo,  Egypt,  and  by  Dr.  Walter,  Dr.  Markoe,  and  Dr.  Little,  of] 
this  country. 

As  executed  by  De  Borsa,  the  operation  is  one  of  great  sim- 
plicity.    The  patient  having  been  placed  in  the  ordinary  position,! 
and  a  staft'with  a  median  groove  having  been  hooked  up  against  | 
the  subpubic  ligament,  the  whole  of  the  membranous  portion  ofj 
the  urethra  is  opened,  so  as  to  expose  the  staff  to  the  extent  of  1 


Eleraens  de  Path.  Chir.,  t.  v.  p.  229. 


MEDIAX    LITHOTOMY. 


289 


about  ten  lines,  by  an  incision  carried  from  without  inwards 
through  the  median  raphe.  The  left  index-finger  is  then  passed 
into  the  bladder,  along  the  staff,  which  is  at  once  withdrawn, 
and  the  prostate  and  neck  of  the  bladder  gently  and  cautiously 
dilated,  with  semirotary  movements  of  the  finger,  to  a  sufiicient 
extent  to  admit  of  the  introduction  of  the  forceps  and  the  extrac- 
tion of  the  stone. 

Instead  of  cutting  fix)m  the  surface  inwards,  Mr.  Allarton 
inserts  the  left  index-finger  into  the  rectum,  and  pressing  its  tip 
firmly  against  the  prostate,  so  as  to  steady  the  staft",  enters  the 
point  of  a  straight  double-edged  knife  in  the  middle  line,  about 
six  lines  in  front  of  the  anus,  and  carries  it  backwards  into  the 
groove  of  the  staff"  for  a  few  lines,  so  as  to  divide  the  apex  of  the 
prostate,  the  opening  in  the  membranous  urethra  and  the  superfi- 
cial structures  being  enlarged  by  cutting  upwards,  as  the  knife  is 
withdrawn,  so  that  the  external  wound  varies  from  three-quar- 
ters of  an  inch  to  an  inch  and  a  half  in  length,  in  accordance 
with  the  presumed  size  of  the  concretion.  The  operation  is  then 
completed  as  in  the  method  of  De  Borsa,  Mr. 
Allarton  having  abandoned  all  dilators  except  the 
finger.^  In  children,  however,  it  will  be  safer  to 
use  the  director  of  Dr.  Little,  of  iSTew  York,  repre- 
sented in  fig.  84,  for  conducting  the  finger  and 
forceps  into  the  bladder. 

The  advantages  claimed  for  this  operation  over 
the  lateral  procedure  are,  that  there  is  less  risk  of 
hemorrhage ;  that  the  prostate  gland,  save  a  slight 
notch  at  its  apex,  and  the  seminal  ducts  are  not 
injured ;  that  there  is  no  danger  of  infiltration  of 
urine  from  division  of  the  pelvic  fascia ;  and  that 
the  wound  closes  more  rapidly.  As  an  oti'set  to 
these  advantages,  it  should  be  stated,  that  the 
rectum  is  in  greater  danger  of  being  wounded ; 
that  the  bulb  is  almost  invariably  divided :  and 
that,  on  account  of  the  necessarily  limited  extent 
of  the  incision,  and  the  danger  of  bruising  or 
lacerating  the  neck  of  the  bladder  and  the  pros- 


Fig.  84. 


Little's  Director. 


'  A  Treatise  on  Median  Lithotomy,  London,  1863,  p.  123. 


19 


290 


TREATMENT  OF  STONE  IN  THE  BLADDER. 


tate,  tlie  operation  is  only  adapted  to  small  calculi.  That 
this  last  objection  is  a  most  serious  one,  is  shown  by  the  ana- 
lysis of  Mr.  C.  Williams  of  64  cases  of  median  lithotomy  at 
the  N'orfolk  and  IsTorwich  Hospital.^  The  entire  number  of 
deaths  was  13  ;  and  in  no  instance  did  recovery  result  when  the  ; 
stone  weighed  over  three  drachms  and  two  scruples,  except  in 
the  case  of  a  man,  forty  years  of  age,  in  which  the  concretion 
exceeded  four  ounces  and  a  half,  but  it  ^vas  followed  by  sloughing 
of  the  rectum  and  perineum,  and  the  establishment  of  a  perma- 
nent perineo-recto-vesical  fistule.  It  is  proper  to  add  that  all 
the  fatal  terminations  occurred  between  the  fifty-second  and 
sixty-fourth  year. 

The  results  of  median  lithotom}^  are  shown  in  the  following 
table,  from  which  the  cases  of  Mr,  Allarton  are  excluded,  as 
their  accuracy  is  doubted  by  English  authors. 

Table  of  350  Cases  of  Median  Lithotomy. 


Operators. 

Cases. 

Recoveries 

Deaths. 

Proportion. 

American  surgeons 
Reyer,  of  Cairo     .... 
NorfoUi  and  Norwich  Hospital     . 
Penaberton,  of  Birmiugliam 

205 
56 
64 
25 

350 

196 

47 
51 
34 

9 

9 

13 

1 

1   in  23.77 
1   in    6.33 
1   in    4.93 
1   in  35 

Total 

318 

32 

1   in  10.93 

At  least  two  so-called  improvements  have  been  made  in  the 
median  operation  by  combining  with  it  the  ordinary  lateral  sec- 
tion of  the  prostate.  Of  these,  the  medio-lateral  procedure  of 
Mr.  Henry  Lee  has  already  been  referred  to  at  page  254. 

The  second  modification  is  that  introduced  by  Professor 
Buchanan,  of  Glasgow,  in  1847,  and  consists  in  making  the  inci- 
sions on  a  staft'  bent  at  a  right  angle  three  inches  from  the  end, 
and  deeply  grooved  on  its  left  side,  as  represented  in  fig.  85,  with 
a  straight,  narrow  scalpel,  which  is  fitted  to  stab  as  well  as  to 
cut.  The  staft',  introduced  into  the  urethra,  is  moved  backwards 
and  forwards  on  the  left  index-finger  in  the  rectum  until  the 
angle  corresponds  with  the  apex  of  the  prostate  gland,  when  the 


'  Holmes's  System  of  Surgery,  2d  ed.,  vol.  iv.  p.  1078. 


RECTO-VESICAL    LITHOTOMY. 


291 


Fiff.  85. 


handle  is  depressed  towards  the  abdomen,  through  which  manoeu- 
vre the  angle  is  made  prominent  in  the  perineum  at  the  verge  of 
the   anus.     The   instrument   is   now   maintained 
firmly  in  its  position  by  an  assistant,  when  the 
operator,  with  the  finger  still  in  the  bowel,  holds 
the  knife  horizontally,  with  the  edge  towards  the 
left  side,  and  transfixes  the  superficial  structures, 
until  the  point  is  in  the  groove  of  the  stafif.     The 
knife  is  then  pushed  steadily  onwards  until  the 
bladder  is  reached,  as  denoted  by   the  escape  of 
urine,  and  during  its  withdrawal,  an  incision  is 
made  downwards  and  outwards,  for  nearly  three- 
quarters  of  an  inch,  in  the  direction  of  the  tubero- 
sity of  the  ischium,  and  then  directly  downwards 
to  the  same  extent. 

In  this  operation,  the  left  lateral  lobe  of  the 
prostate  is  divided,  while  the  bulb  and  rectum  are 
out  of  danger.  In  addition  to  these  advantages. 
Dr.  Buchanan  claims  that  it  is  more  easily  and 
rapidly  executed  than  the  lateral  operation,  and 
that  it  is  attended  with  less  risk  of  hemorrhage 
and  urinary  infiltration.  The  mortality  of  the 
procedure,  as  given  by  its  originator,^  is  about  1 
in  12,  six  deaths  having  resulted  in  upwards  of 
sixty  cases. 


Buchanan's  Rec- 
tangular Statf. 


Art.  IV.— RECTO-VESICAL  LITHOTOMY. 

The  recto-vesical  operation,  devised  in  1816,  by  Sanson,  of 
Paris,  and  formerly  much  practised  by  the  Italian  surgeons,  is 
now  almost  obsolete.  When  first  introduced,  it  Avas  invested 
with  a  sort  of  dclat,  on  account  of  its  supposed  advantages,  of 
which  not  the  least  striking  is  its  apparent  simplicity,  and  the 
facility  with  which  it  may  be  executed.  It  was  also  imagined 
that  it  was  entirely  free  from  the  risk  of  hemorrhage,  and  that, 
from  the  dependent  character  of  the  wound,  it  admitted  of  the 
more  easy  extraction  of  the  foreign  body.     Experience,  however. 


'  Medical  Times  aud  Gazette,  March  31,  186D,  p.  3U. 


292  TREATMENT    OF    STONE    IN    THE    BLADDER. 

showed  tliat  it  was  often  succeeded  hy  extensive  suppuration  of 
the  connective  tissue  within  the  pelvis,  thus  endangering  both 
part  and  system ;  that  the  ejaculator}^  ducts,  and  even  the  semi- 
nal vesicles,  were  occasionally  wounded  ;  and  lastly,  though  not 
least,  that  it  was  liable  to  leave  a  fistulous  communication  be- 
tween the  bladder  and  the  rectum.  These  disadvantages  more 
than  counterbalance  any  benefits  which  it  was  supposed  to 
possess  by  Sanson  and  his  followers.  It  is  not  surprising,  there- 
fore, that  it  should  soon  have  fallen  into  disuse. 

Although  the  recto-vesical  section  has  been  discarded,  as  one 
of  the  regular  operations  of  lithotomy,  circumstances  may  arise 
which  may  render  it  not  only  justifiable  but  highly  proper. 
Thus,  the  stone  may  be  lodged  in  the  bas-fond  of  the  bladder, 
or  it  may  be  impacted  in  one  of  the  ureters,  or  it  may  bulge  into 
the  rectum,  forming  a  tumor  from  two  to  three  inches  above  the 
verge  of  the  anus,  or,  finally,  it  may  be  too  large  to  extract  by 
the  lateral  incision. 

A  staff  with  a  central  groove  being  introduced  into  the  blad- 
der, and  confided  to  an  assistant  who  holds  it  firmly  in  the 
mediaia  line,  the  surgeon  inserts  his  left  index-finger,  on  the 
palmar  surface  of  which  the  blade  of  a  straight  bistoury  rests 
flatwise,  into  the  rectum  for  about  one  inch.  He  then  turns  the 
edge  of  the  knife  upwards  with  his  right  hand,  and  pierces  the 
anterior  wall  of  the  bowel,  so  that  the  groove  of  the  staft'  is 
reached  just  in  front  of  the  prostate,  when,  by  withdrawing  the 
knife,  he  divides  the  rectum,  the  anterior  fibres  of  the  levator 
ani,  the  sphincter,  the  connective  tissue,  and  the  integument  in 
the  median  raphd,  to  the  extent  of  one  inch.  Reentering  the 
knife,  with  its  point  downwards,  in  the  groove  of  the  staft',  he 
pushes  it  directly  onwards  in  the  middle  line,  dividing  the  pros- 
tate, the  neck  of  the  bladder,  and  the  trigone,  sufficiently  to 
admit  of  the  removal  of  the  stone. 

With  a  view  to  prevent  the  formation  of  a  recto-vesical  fistule, 
Professor  Louis  Bauer,'  in  1859,  opened  the  rectum  above  the 
prostate,  in  the  trigone,  the  bowel  having  previously  been  ex- 
panded with  Sims's  speculum.  The  wound  was  closed  with  five 
silver  sutures,  which  were  removed  on  the  eighth  day,  when  the 
union  was  perfect.     Dr.  Noyes,  in  1860,  performed  a  somewhat 

'  Amer.  Med.  Gaz.,  Sept.  1859. 


SUPRAPUBIC    LITHOTOMY. 


293 


similar  operation,  closing  the  wound  with  metallic  sutures,  sup. 
ported  by  a  leaden  button. 

Table  showmg  the  Results  of  83  Cases  of  Recto-  Vesical 
Lithotorriy} 


Operator. 

Cases. 

Cures. 

Fistula. 

Deaths. 

Proportion. 

Vacca 

24 

19 

3 

5 

1  in    4.8 

Giorgi 

10 

10 

1 

0 

Cavarra  . 

10 

9 

1 

1 

1  in  10 

Janson     . 

7 

4 

0 

3 

1   in    2.33 

Cittadini . 

5 

4 

2 

1 

1   in    5 

Dupuytren 

4 

3 

2 

1 

1   in    4 

Moschi     . 

3 

3 

0 

0 

( 
i 

8 

5 

1 

3 

1  in    2.66 

Different  operators 

9 

7 

1 

2 

1  in    4.5 

3 

3 

1 

0 

83 

67 

112 

16 

1  in    5.18 

Art.  v.— suprapubic  LITHOTOMY. 

In  the  suprapubic,  or  high  operation,  or  epicj^stotomy,  as  this 
procedure  is  variously  termed,  the  bladder  is  opened  above  the 
pubes,  in  the  direction  of  the  linea  alba.  The  proceeding, 
although  objectionable  as  a  general  rule,  may  occasionally  be 
resorted  to  with  advantage,  and,  therefore,  requires  brief  con- 
sideration in  this  place.  The  operation,  which  originated  with 
Pierre  Franco,  in  1561,  was  first  performed  in  this  country  in 
1824,  by  Professor  Gibson,  of  Philadelphia,  in  the  case  of  an  old 
gentleman  of  Virginia,  who  was  affected  with  great  enlargement 
of  the  prostate  gland,  and  who  died  soon  after  from  the  effects 
of  peritonitis,  consequent  upon  urinary  effusion. 

Jean  de  Dot,  a  blacksmith  of  Amsterdam,  in  the  17th  century, 
cut  himself  in  the  linea  alba,  above  the  pubes,  and  extracted  a 
stone  from  his  bladder  the  size  of  a  hen's  egg.  The  stone,  the 
knife,  and  the  portrait  of  the  operator  are  preserved  to  this  day 
in  the  museum  at  Leyden. 

The  chief  advantages  of  the  high  operation  are,  that  it  is  free 
from  hemorrhage ;  that  it  does  not  expose  the  patient  to  injury 
of  the  rectum  and  the  ejaculatory  ducts ;  that  there  is  no  risk 

'  Kduig  :  Journal  der  Chirurgie  von  Graefe  und  Walther,  B.  8,  S.  529. 
2  These  cases  are  added  to  the  cures,  or,  rather,  recoveries,  only  5G  of  which 
were  complete. 


294  TREATMENT    OF    STONE    IN    THE    BLADDER. 

from  inflammation  of  the  neck  of  the  bladder;  that  it  may  be 
performed  where  the  lateral  section  is  impracticable,  on  account 
of  impassable  stricture  of  the  urethra,  excessive  depth  of  the 
perineum,  deformity  of  the  pelvis,  or  great  enlargement  of  the 
prostate  gland;  and,  lastly,  that  it  admits  of  the  more  easy 
removal  of  a  large,  attached,  or  encysted  calculus.  As  an  offset 
to  these  advantages,  it  is  to  be  remarked  that  the  procedure  is 
liable  to  be  followed  by  injury  of  the  peritoneum  and  by  urinary 
infiltration,  not  to  say  anything  of  the  difficult}'  of  executing 
it  when  the  abdomen  is  loaded  with  fat,  or  the  bladder  does  not 
ascend  any  distauce  above  the  pubes.  The  latter  of  these 
dangers  may,  however,  in  general,  be  avoided  by  premising  a 
perineal  puncture,  to  serve  as  an  outlet  to  the  urine,  which  thus 
drains  off  as  fast  as  it  reaches  the  neck  of  the  bladder.  The 
former,  too,  may  usually  be  guarded  against,  if  the  precaution 
be  used,  first,  to  distend  the  bladder  thoroughly  before  the  ope- 
ration, and,  secondly,  to  push  the  peritoneum  gently  before  the 
knife  after  cutting  through  the  inferior  part  of  the  linea  alba. 

In  performing  the  operation,  the  patient  is  placed  recumbent, 
upon  a  narrow  table,  with  the  pelvis  slightly  elevated  on  a 
pillow,  so  as  to  throw  back  the  intestines,  the  legs  hanging 
loosely  over  its  lower  edge,  and  the  feet  resting  upon  a  chair. 
The  head  and  shoulders  are  sometimes  raised  by  pillows,  to 
relax  the  abdominal  muscles.  An}-  hair  that  may  cover  the 
suprapubic  region  is  to  be  removed  with  the  razor  or  scalpel. 
The  bladder,  if  not  previously  distended  by  the  retention  of  its 
own  contents,  is  now  filled  with  tepid  water  until  it  rises  a  con- 
siderable distance  above  the  pubes.  Trifling  as  this  part  of  the 
operation  apparently  is,  it  cannot  be  performed  with  too  much 
care,  to  prevent  the  rupture  of  the  organ  ;  an  accident  which 
happened  occasionally  in  the  hands  of  the  older  lithotomists. 

These  preliminaries  being  duly  attended  to,  the  surgeon, 
standing  on  the  left  side  of  the  patient,  makes  an  incision  from 
three  inches  to  three  inches  and  a  half  in  length,  commenc- 
ing at  the  pubic  symphysis,  and  extending  upwards  towards 
the  umbilicus,  in  the  direction  of  the  linea  alba.  It  should 
pass  through  the  skin*  and  connective  tissue  down  to  the 
aponeurosis  of  the  abdominal  muscles.  This  structure,  being 
thus  exposed,  is  next  cautiously  divided  to  the  extent  of  an 
inch  and  a  half  or  two  inches.     Any  vessels  that  may  bleed 


SUPRAPUBIC    LITHOTOMY.  295 

are  now  secured;  or,  what  will  usually  answer  equally  well, 
compressed  by  the  finger  of  an  assistant.  'J'he  bladder  will  now 
be  found  at  the  bottom  of  the  wound,  forming  a  tolerably  large, 
fluctuating  tumor,  and  invested  merely  by  a  thin  layer  of  con- 
nective tissue.  To  divide  this,  a  few  gentle  touches  of  the  knife 
are  sufficient ;  or,  what  is  better  and  more  safe,  the  dissection 
may  be  eflected  with  the  rounded  steel  end  of  the  handle  of  the 
instrument.  Conducted  in  this  manner,  there  is  hardly  any 
possibility  of  wounding  the  peritoneum,  the  great  danger  in  this 
stage  of  the  operation.  If  the  bladder  is  quite  prominent,  it 
should  now  be  transfixed  by  a  delicate  tenaculum ;  otherwise  it 
should  be  rendered  sufficiently  so  by  the  introduction  of  a  sound 
through  the  urethra.  In  either  case,  it  is,  I  conceive,  a  matter 
of  paramount  importance  to  secure  the  bladder  before  it  is  in- 
cised, in  order  to  prevent  it  from  collapsing,  and  sinking  down 
behind  tlie  symphysis ;  an  occurrence  which  cannot  fail  greatly 
to  embarrass  the  subsequent  steps  of  the  operation.  An  incision 
is  next  made  into  the  anterior  surface  of  the  viscus,  from  the 
level  with  the  pubic  symphysis  nearlj'  to  the  neck  of  the  blad- 
der, when  the  left  index-finger,  which  is  at  once  introduced,  is 
used  as  a  searcher  to  ascertain  the  situation  and  volume  of  the 
stone.  The  opening  is  afterwards  enlarged,  with  a  probe-pointed 
bistoury,  to  any  extent  that  may  be  required;  the  forceps  are 
introduced  ;  and  the  stone  is  seized  and  removed.  The  wound 
in  the  bladder  is  now  closed  accurately  by  sutures,  one  end  being 
brought  out  at  the  external  opening  as  originally  suggested  by 
Professor  Bruns,^  of  Tiibingen,  and  the  edges  of  the  external  in- 
cision approximated  by  several  points  of  the  twisted  suture, 
except  at  the  lower  angle,  where  a  small  opening  is  left  for 
drainage.  Subsequent  distention  of  the  bladder  may  be  pre- 
vented by  the  methodical  use  of  the  soft  catheter. 

It  has  been  seen  that  the  chief  danger  of  this  operation  is 
injur}^  of  the  peritoneum.  When  this  is  followed  by  the  ad- 
mission of  urine,  even  in  the  smallest  possible  quantity,  into  the 
general  cavity  of  the  abdomen,  violent  inflammation  is  sure  to 
ensue,  and  to  destroy  the  patient  in  a  few  days.  Mere  lesion  of 
the  membrane,  without  extravasation,  is,  on  the  contrary,  com-  ^ 
paratively  harmless. 

'  Deutsche  Klinik,  No.  15,  1858. 


296 


TREATMENT  OF  STONE  IN  THE  BLADDER. 


When  abscesses  form  in  consequence  of  an  escape  of  the  urine 
into  the  connective  tissue  around  the  wound,  early  and  free  in- 
cisions are  made,  followed  by  the  warm-water  dressings.  If  the 
matter  be  allowed  to  remain  pent  up,  serious  mischief  must 
result  from  its  tendency  to  burrow,  and  irritate  the  peritoneum. 

In  an  elaborate  paper  on  suprapubic  lithotomy,  Dr.  C.  W. 
Dulles,  of  Philadelphia,  has  collected  465  cases  of  this  operation, 
of  which  330  recovered,  and  135,  or  1  in  3.44,  died.^  In  19 
patients  the  lateral  operation  had  been  previously  ineffectually 
practised  for  large  stones,  and  not  less  than  7  recovered.  42 
cases,  with  14  deaths,  occurred  in  the  hands  of  American  sur- 
geons. In  estimating  the  results  of  epicystotomy,  it  should  be 
remembered  that  the  operation  has  generally  been  resorted  to  for 
calculi  of  much  larger  size  than  have  been  removed  by  the  lateral 
method.  An  examination  of  the  following  table,  framed  by  Dr. 
Dulles,  will  show  that,  while  lateral  lithotomy  gives  far  better 
results  for  stones  weighing  less  than  two  ounces,  the  suprapubic 
operation  is  attended  by  a  smaller  rate  of  death  when  the  con- 
cretion exceeds  two  ounces  in  weight.  The  figures  in  the  lateral 
operation  are  taken  from  the  treatise  of  Mr.  Crosse. 


Table  showing  the  Mortality  with  Calculi  of  Same  Weights. 


Lateral  Operation. 

SCPRAPDBIC 

Operation. 

Weight. 

Recovered. 

Died. 

Total. 

Death  ratio. 

Recovered. 

Died. 

Total. 

Death  ratio. 

Under  gj 

482 

47 

529 

1  :  11.25 

11 

3 

14 

1  :  4.66 

.^J-iJ 

101 

18 

119 

1  :    6.61 

17 

4 

21 

1  :  5.25 

oU-i'J 

19 

16 

35 

1  :    2.18 

10 

4 

14 

1  :  3.50 

.=;iij-iv 

4 

7 

11 

1  :    1.57 

13 

6 

19 

1  :3.16 

Siv-v 

2 

3 

5 

1  :    1.66 

9 

7 

16 

1  :  2.28 

.=;v-vj 

2 

2 

0  :    2.00 

7 

4 

11 

1  :  2.75 

5vj-vij 

3 

2 

1  :    1.00  j 

1 

1 

2 

1  :  2.00 

Art.  VI.— EXTRAPELVIC  LITHOTOMY. 

In  the  chajiter  on  Cystocele,  as  well  as  in  other  portions  of 
this  treatise,  mention  is  made  of  the  fact  that  urinary  calculi  are 
occasionally  situated  on  the  outside  of  the  pelvic  cavity,  being 
either  developed  there,  or  carried  thither  by  the  prolapsed  blad- 
der.    The  occurrence,  although  not  frequent,  is  worthy  of  par- 


'  Araer.  Journ.  Med.  Sciences,  July,  1875,  p.  39. 


EXTRAPELVIC    LITHOTOMY.  297 

ticular  attention,  as  it  involves  important  principles  of  treatment. 
The  most  common  site  of  the  foreign  body'  is  the  groin,  but  in 
some  instances  the  concretion  descends  into  the  scrotum,  the 
ischiatic  notch,  or  the  pudendum,  forming,  either  by  itself,  or 
along  with  the  bowel,  a  considerable-sized  tumor,  of  a  firm  con- 
sistence, or  soft  at  one  point,  and  hard  at  another.  Occasionally 
the  substance  is  lodged  partly  within  the  pelvis  and  partly  with- 
out; and  it  should  be  remembered,  moreover,  that  there  is 
sometimes  a  number  of  calculi,  as  in  the  famous  case  of  Ruysch,^ 
in  which  there  were  not  less  than  forty-two,  and  in  the  still 
more  remarkable  one  recorded  by  Mr.  Paget,^  of  Leicester,  Eng- 
land, in  which  a  pudendal  cystocele  contained,  in  addition  to 
innumerable  small  concretions,  a  stone  weighing  twenty-seven 
ounces. 

The  symptoms  of  this  form  of  calculus  do  not  difter  materially 
from  those  which  attend  the  ordinary  aifection.  The  patient  is 
tormented  with  pain  in  the  bladder  and  a  frequent  desire  to 
pass  water,  which  is  often  evacuated  with  great  difficulty  and 
only  after  much  straining.  Sounding  aftbrds  little  or  no  light, 
except  of  a  negative  character,  or  where  the  calculus  is  lodged 
partly  in  the  pelvis,  when  it  may  sometimes  be  touched  by  the 
instrument,  and  thus  furnish  the  usual  evidences  of  the  presence 
of  a  foreign  body.  It  deserves  to  be  remembered  that,  where  a 
number  of  concretions  exist,  some  may  lie  loose  in  the  body  of 
the  bladder,  while  the  rest  are  lodged  in  the  prolapsed  portion 
of  the  organ.  Such  a  case,  in  which  two  operations  were  per- 
formed before  complete  riddance  was  effected,  is  related  in  the 
fourteenth  volume  of  the  Edinburgh  Medical  and  Surgical  Jour- 
nal, and  is  of  great  interest  in  its  practical  relations.  In  general, 
the  stone,  when  situated  externally,  can  be  detected  only  by  the 
touch:  when  several  concretions  are  present,  a  distinct  crack- 
ling noise  may  occasionally  be  elicited  by  rubbing  them  against 
each  other. 

The  proper  treatment,  in  all  cases  of  extrapelvic  calculi,  is  to 
make  an  incision  through  the  coats  of  the  prolapsed  portion  of 
tlie  bladder,  as  it  lies  in  its  abnormal  situation,  to  extract  the 
foreign  body  with  the  fingers,  scoop,  or  forceps,  and  to  retain  a 

'  Obs.  Anatom.  Chir.  Obs.,  i.  p.  1,  1691. 

2  Loudon  Med.  aud  Physical  Journal,  vol.  vi.  p.  391,  1801. 


29  S 


TREATMENT  OF  STOXE  IX  THE  BLADDER, 


e-atheter  in  the  organ  until  the  wound  is  thoroughly  cicatrized, 
lest  the  parts  should  suffer  from  urinary  infiltration.     Such  an 
operation  is  not  dangerous,  because  the  tumor  in  its  descent  does 
not  drag  down  the  peritoneum,  and  there  is,  therefore,  no  proper 
hernial  sac.     It  is  only  when  the  case  is  complicated  with  entero- 
cele  that  there  is  likely  to  be  a  serous  investment,  although  this 
need  not  necessarily  be  divided.     When  the  concretion  projects 
into  the  pelvis  by  its  larger  extremity,  the  lateral,  bilateral,  or 
sujirapubic  operation  may  become  necessary,  as  complete  rid- 
dance, under  such  circumstances,  is  hardly  to  be  expected  bj 
external  incision.     Several  examples  have  been  reported  of  th( 
spontaneous  discharge   of  vesical   calculi   from  the  groin  an( 
scrotum.     In  the  case  of  a  shoemaker,  recorded  by  Graefe,^ 
scrotal  calculus,  of  twenty  years'  standing,  and  weighing  twenty-^ 
six  ounces,  ruptured  the  scrotum  and  escaped,  during  strainingi 
at  stool. 

General  Results  of  the  Different  3Iethods  of  Lithotomy. 

The  folloAving  table  presents  the  general  results  of  the  more 
important  operations  described  in  the  preceding  pages. 


Methods 


Lateral  operation^. 
Bilateral  operation 
Median  operation  . 
Recto-vesical  operation 
Suprai3ubic  operation    . 


Cases. 

Cares. 

Deaths. 

10,150 

9036 

1114 

536 

495 

41 

350 

318 

32 

83 

67 

16 

465 

330 

135 

11,584 

10,246 

1338 

Satio  of  deaths. 


1  in  9.11 
1  in  13.07 
1  in  10.93 
1  in  5.18 
1  in  3.44 

1  in  8.65 


'  Graefe's  und  Waltlier'e  Journal,  vol.  iii.  p.  399. 

2  Based  upon  the  statistics  of  American  surgeons,  the  table  at  p.  276,  and] 
the  practice  of  Cheselden,  Listen,  B.  B.  Cooper,  Fergusson,  Keith,  SouthamJ 
Crichton.  Teale.  Balassa,  Grant,  Curran,  Cutcliffe,  Raddock,  Brett,  Pollak,] 
Zett,  Pouteau,  Vericel,  Mormeaux,  Petruni,  Kern,  Chelius,  and  Wattmanu. 


CHAPTER    X. 

STONE  IN  THE  BLADDER  OF  THE  FE:\rALE. 

"WoMKN  are  much  less  lia1)le  to  urinary  calculi  than  men,  the 
pi  oportion  being  about  one  to  t^venty,  the  ditt'erence  beino;  due, 
in  part  at  least,  to  the  shortness,  width,  and  dilatability  of  the 
female  urethra,  which  thus  permit  the  concretion,  in  most  cases, 
to  pass  ofi'  immediately  after  it  descends  from  the  kidneys,  or 
after  it  is  formed  in  the  bladder.  In  the  male,  on  the  contrary, 
the  smallest  particle  of  earthy  matter  is  liable  to  be  retained, 
and  to  become  the  nucleus  of  a  stone.  The  period  of  life  at 
which  they  are  most  subject,  to  stone  is  from  the  age  of  twenty 
to  that  of  fifty. 

The  symptoms  which  attend  this  affection  in  the  female  are 
similar  to  those  which  characterize  it  in  the  other  sex,  the  most 
urgent  being  incontinence  of  urine  and  bearing-down  j)ains.  In 
sounding,  the  patient  is  placed  upon  her  back,  on  the  edge  of 
the  bed,  and  the  instrument,  a  short  steel  rod,  slightly  curved 
at  the  extremity,  is  carried  about  through  the  interior  of  the 
bladder,  so  as  to  explore,  if  necessary,  every  recess  of  this  organ. 
In  young  children,  the  finger  may,  if  deemed  advisable,  be  in- 
serted into  the  rectum  ;  but  in  grown  subjects  it  is  best  ahvays 
to  introduce  it  into  the  vagina. 

Stones  in  the  female  occasionally  acquire  an  enormous  bulk, 
and  may  seriously  interfere  with  labor  by  preventing  the  descent 
of  the  child's  head.  In  general,  however,  they. are  comparatively 
small,  and  do  not  weigh  more  than  six,  eight,  or  ten  drachms. 
In  some  instances,  although  rarely,  the  concretion  projects  into 
[the  urethra;  and  occasionally  it  has  been  known  even  to  pro- 
ttrude  at  the  outer  opening  of  that  passage.  When  this  is  the 
(Case,  the  patient  almost  always  s.ufi:ers  from  incontinence  of 
jurine,  and  from  the  various  other  evils  incident  to  that  disagree- 
jable  aft'ection. 

I     A  number  of  cases  are  upon  record  in  which  calculi  of  large 
!>ize  have  been  exjielled  spontaneously  from  the  female  bladder. 


300     STOXE  IX  THE  BLADDER  OF  THE  FEMALE. 

The  urethra,  under  such  circumstances,  is  gradually  dilated,  and 
probably  also  much  shortened,  from  the  pressure  exerted  upon 
it  by  the  foreign  body,  which  thus  paves  the  way  for  its  own 
evacuation.  The  expulsion  is  sometimes  effected  suddenly,  per- 
haps under  the  influence  of  a  violent  attempt  at  micturition,  or 
an  effort  at  coughing,  sneezing,  or  vomiting ;  but,  in  general,  it 
is  accomplished  slowly,  and  with  more  or  less  pain  and  difficulty 
in  voiding  the  urine.  Instances  of  the  spontaneous  discharge  of 
stones,  weighing  two,  three,  four,  five,  and  even  twelve  ounces, 
are  mentioned  by  Callot,  Molyneux,  Beards,  Baker  Brown, 
Middleton,  Botti,  Klauder,  Garden,  Wilks,  and  others.  Occa- 
sionally the  calculus  is  evacuated  through  the  vagina,  in  conse- 
quence of  ulceration  of  the  anterior  wall  of  this  tube.  Such  an 
occurrence  is  fortunately  rare,  for  it  is  generally,  if  not  always, 
followed  by  a  permanent  tistule. 

Treatment. — A^arious  plans  have  been  proposed  and  practised 
for  the  extraction  of  calculi  from  the  female  bladder.  Of  these 
only  a  few  need  be  considered,  as  the  rest  are  either  obsolete,  or 
are  seldom  required. 

I.  Dilatation. — The  method  of  dilatation  has  been  practised 
from  an  early  period  of  the  profession,  and  has  been  received 
with  various  degrees  of  favor  by  different  operators.  It  is  more 
particularly  adapted  to  small  concretions,  unaccompanied  with 
an}'  serious  disease  of  the  urethra  and  neck  of  the  bladder.  The 
dilatation  may  be  effected  slowly  by  sponge  tents,  but  this  pro- 
cedure is  now  generally  discarded,  as  it  is  liable  to  be  followed 
by  incontinence  of  urine.  Eapid  dilatation,  on  the  other  hand, 
is  not  open  to  this  objection,  although  calculi  measuring,  with 
the  forceps,  two  inches  in  diameter  have  been  successfully  re- 
moved in  this  way. 

The  patient  being  under  the  influence  of  chloroform,  a  conical 
steel  bougie,  or  the  dilator  represented  in  tig.  86,  is  introduced 
and  expanded  rapidly  and  sufficiently  far  to  admit  the  finger 
and  the  forceps.  Greater  accuracy,  when  the  size  of  the  stone 
is  determined,  as  to  the  amount  of  dilatation  necessary,  in  any 
given  instance,  may  be  attained  by  the  use  of  Simon's  specula, 
represented  in  fig.  32,  the  largest  of  which  measures  two-fifths 
of  an  inch  in  diameter.  In  the  event  of  difficulty  being  encoun- 
tered in  extracting  the  stone,  it  should  be  crushed  by  powerful 
forceps,  and  removed  piecemeal. 


LITHOTRITY. 


301 


The  risks  of  incontinence  after  the  two  methods  of  dilatation 
are  fairly  set  forth  in  a  table  by  Mr.  Bryant.^     Of  13  cases  of 


Fig.  86. 


Urethral  Dilator. 


slow  dilatation,  fonr  recovered  with  incontinence ;  while  of  15 
cases  of  rapid  dilatation,  all  recovered  without  this  distressing 
feature.     These  facts  do  not  require  comment. 

II.  Lithotrity. — Crushing  may  be  employed  when  the  bladder 
is  healthy,  and  when  the  stone  is  comparatively  soft,  and  yet  so 
large  as  to  render  it  impossible  to  extract  it  by  dilatation  of  the 
urethra.  Indeed,  I  am  well  satisfied  that  almost  any  calculus, 
unless  extremely  hard  or  voluminous,  may  be  disposed  of  in  this 
way,  and  it  is  only  surprising  that  the  procedure  is  so  seldom 
employed.  The  object  may  be  eftected  either  with  stout  forceps, 
or  a  sliort  lithotrite,  the  fragments  being  removed  at  once  with 
small  lithotomy  forceps  and  the  syringe.  Of  13  operations,  tabu- 
lated by  Mr.  Bryant,  all  recovered,  but  two  of  the  patients 
suffered  from  incontinence  of  urine.     In  one  of  these  cases,  how- 

'  Med.-Chir.  Trans.,  vol.  xlvii.,  1864,  p.  164. 


302 


STONE    IN    THE    BLADDER    OF    THE    FEMALE. 


Fie;.  87. 


ever,  the  urethra  was  incised  laterally,  and,  in  the  other,  it  had 
been  subjected  to  dilatation  at  intervals  for  three  weeks. 

III.  Lithotomy. — Calculi  may  be  removed  from  the  female 
bladder  by  cutting  operations  in  several  ways.  Whichever 
method  may  be  selected,  the  patient  is  anaesthetized  and  placed 
in  the  ordinary  position,  and  the  incision  made  on  the  staff, 
represented  in  tig.  87. 

o.  Urethral  lithotomy.  In  this  procedure,  the  incision,  made 
with  a  straight  probe-pointed  bistoury,  includes  the  entire  ure- 
tlira  and  neck  of  the  bla<ider.  It  may  be  carried 
directly  upwards  towards  the  pubic  symphysis,  or 
directly  downwards,  or  downwards  and  outwards 
on  both  sides,  or  downwards  and  outwards  on  one 
side,  towards  the  tuberosity  of  the  ischium,  as  may 
suit  the  ideas  of  the  surgeon  or  the  requirements  of 
the  case.  When  the  concretion  is  very  large,  the 
last  procedure,  which  is  analogous  to  the  lateral  ope- 
ration in  the  male,  will  give  an  abundance  of  room. 
In  this  way  the  late  Dr.  J.  Kearney  Kodgers,  of  JS^ew 
York,  succeeded  in  extracting  a  uric  acid  calculus, 
which  weighed  nine  ounces  and  five  drachms,  and 
measured  nine  inches  and  a  half  in  its  long,  and 
seven  inches  and  three-quarters  in  its  short  circum- 
ference. No  incontinence  of  urine  followed,  and  the 
patient  was  perfectly  well  thirty  years  afterwards. 

The  great  objection  to  incising  the  urethra  is  its 
liability  to  be  followed  by  incontinence  of  urine, 
which  occurred  in  9  of  20  cases  tabulated  by  Mr, 
Bryant.  For  this  reason,  the  operation  should  be 
avoided. 

M.  Vaginal  lithotomy.  The  removal  of  a  calculus  by 
colpocystotomy  or  cutting  into  the  bladder  through 
the  anterior  wall  of  the  vagina,  first  practised  by 
Rousset  in  the  latter  part  of  the  sixteenth  century,  was  warmly 
advocated  by  Vidal,  and  is  recommended  by  Dr.  Marion  Sims, 
Dr.  Emmett,  and  Dr.  Aveling,  of  Sheffield,  England,  who  has 
made  an  interesting  contribution  on  the  subject.'  The  operation 
may  be  required  for  very  large  calculi,  in  which  dilatation  is 


Female  Staff. 


'  Trans.  Obstetrical  Society,  voL  v.,  1864,  p.  1. 


LITHOTOMY.  303 

inapplicable,  or  in  which  the  condition  of  the  bladder  forbids 
lithotrity,  but  it  should  not  be  practised  when  it  is  possible  to 
avoid  it.  The  vagina  having  been  expanded  with  a  duck-bill 
speculum,  and  the  vesico- vaginal  septum  rendered  prominent  by 
pressing  the  handle  of  the  staff  backwards,  a  lithotomy  knife  is 
thrust  into  the  groove  of  the  staff,  and  an  incision,  commencing 
one  inch  and  a  quarter  posterior  to  the  meatus,  carried  exactly 
in  the  middle  line,  sufficiently  far  for  the  easy  extraction  of  the 
stone.  The  edges  of  the  w^ound  are  then  brought  together,  as 
in  the  operation  for  vesico- vaginal  fistule,  and  the  after-treatment 
conducted  on  similar  principles. 

Of  35  cases  collected  by  Dr.  Aveling,  only  one  proved  fatal,  but 
from  the  fact  that  the  majority  of  operations  were  performed 
before  the  recent  improvements  in  sewing  up  the  wound,  the  pro- 
bability is  that  the  majority  were  the  subjects  of  incontinence  of 
urine.  M.  Vidal  had  thirty  cases  without  a  single  death  ;  but  a 
fistule  often  followed.  Of  43  cases  in  the  hands  of  American 
surgeons,  all  were  successful.  Dionis,  who  operated  by  double 
lateral  incisions,  subjected  three-fourths  of  his  patients  to  incon- 
tinence of  urine.  Hence,  the  operation  should  only  be  performed 
when  the  stone  can  be  removed  in  no  other  way. 
I  y.  Suprapubic  lithotomy.  Finally,  when  the  stone  is  of  un- 
I  usual  magnitude,  and  vaginal  lithotomy  is  deemed  unadvisable, 
epicystotomy  may  have  to  be  resorted  to.  Professor  Parker,  of 
[New  York,  has  opened  the  bladder  four  times  above  the  pubes, 
jand  his  patients  made  satisfactory  recoveries.  Dr.  Pitcher,  Dr. 
IWeber,  and  Dr.  Westmoreland  have  each  had  a  case  in  young 
Ichildren,  and  with  equal  success.  Indeed,  the  operation  seems 
jto  be  more  favorable  in  females  than  in  males.  Thus,  of  82 
leases  in  females  tabulated  by  Dr.  Dulles, '  72  recovered,  and  10, 
or  1  in  8.20,  died;  while  of  383  males,  258  recovered,  and  125, 
or  1  in  3.06,  proved  fatal. 

AVhatever  procedure  be  adopted,  I  conceive  it  to  be  a  matter 

3f  primary  importance  that  the  patient  should  be  kept  perfectly 
lit  rest  and  recumbent,  until  the  parts  have  regained  their  origi- 
nal tone.     This  shoiild  be  done  not  merely  where  incision  has 

xicn  practised,  but  even  where  the  operation  is  limited  to  dila- 
l.ation.  By  observing  this  precaution,  the  risk  of  incontinence 
;>f  urine  will  be  greatly  diminished. 

I  '   Op.  cit.,  p.  47. 


304    STONE  IN  THE  BLADDER  OF  THE  FEMALE. 

It  occasionall}'  happens  that  urinary  calculi  are  met  with  in 
pregnant  or  parturient  females,  and  that  they  interfere  with 
natural  labor.  Should  the  true  cause  of  the  obstruction  be  over- 
looked, both  mother  and  child  may  be  sacrificed,  as  in  the  case 
related  by  Mr.  Threlfall,^  of  Liverpool.  In  any  event,  there  is 
always  risk  of  the  formation  of  a  fistule,  from  sloughing,  the 
result  of  the  pressure  exerted  upon  the  vesico- vaginal  septum  by 
the  stone  and  the  descending  foetal  head. 

The  proper  remedy  is  to  extract  the  stone  during  gestation,  if 
its  presence  be  suspected.  If,  during  labor,  it  be  placed  below 
the  head  of  the  child,  attempts  should  be  made  to  push  it  back 
into  the  body  of  the  bladder  ;  but  when  these  manoeuvres  fail, 
it  must  be  removed  by  one  of  the  operations  already  discussed, 
that  one  being  selected  which  meets  the  requirements  of  each 
individual  case'. 

'  Edinburgh  3Ied.  aud  Surg.  Journ.,  voL  xxxi.  p.  56. 


CHAPTER    XI. 

FOREIGN  BODIES  IN  THE  BLADDER. 

The  foreign  bodies  that  niaj'  find  their  way  into  the  hhidder 
are  too  diversified  in  tlieir  character  to  admit  of  any  very  pre- 
cise enumeration.     The  most  common,  liowever,  as  well  as  tlie 
most  important,  are  portions  of  catheters,  needles,  pins,  balls, 
bits  of  wood,  as  pencils  and  penholders,  fruits  and  kernels,  frag- 
ments of  plants,  as  ears  of  corn  and  stalks  of  wheat,  foetal  debris, 
fragments  of  hone,  needle  cases,  pipe  stems,  glass  tubes,  pebbles, 
and  pessaries.     Such  bodies  may  be  introduced  into  the  bladder 
either  accidentally,  as  in  the  case  of  balls  and  splinters  of  bone ; 
or,  they  may  be  thrust  up  designedly,  but  with  no  intention  of 
leaving  them  in  this  unfortunate  situation.     Many  a  poor  fel- 
low, in  the  act  of  committing  onanism,  has  unwittingly  intro- 
duced a  catheter,  piece  of  straw,  wood,  or  wire,  into  the  uretlira, 
from  which  it  soon  after  slipped  into  the  bladder.     Surgeons 
have  often  broken  off  the  catheter  in  the  bladder,  and  a  bougie 
has  occasionally  met  with  a  similar  mishap.      The  elm-bark 
bougie,  at  one  time  used  a  good  deal  in  the  Southwest,  has 
several  times,  within  my  knowledge,  broken  ofi:'  in  the  bladder, 
from  whicb  it  was  obliged  to  be  subsequently  removed  by  an 
operation.     In  cauterizing  the  neck  of  the  bladder  for  tbe  cure 
of  seminal  weakness  and  other  aftections,  the  cup  of  Lallemand's 
porte-caustique  has  been  repeatedly  left  in  the  interior  of  this 
organ,  much  to  the  annoyance  and  chagrin  of   the  surgeon. 
Accidents  of  a  similar  character  formerly  occasionally  happened 
in  the  operation  of  lithotrity.     Balls  sometimes  enter  the  pelvic 
cavity,  and  from  thence  gradually  find  their  way  into  the  blad- 
der b}^  ulcerative  absorption.     In  the  same  manner  a  fragment 
of  bone,  detached  by  external  violence,  or  the  efl:ects  of  disease, 
has  repeatedly  been  known  to  pass  into  this  organ,  as  have  also 
the  contents  of  dermoid  cysts  of  the  ovary. 

However  introduced,  the  effects  upon  the  foreign  substance 
and  the  bladder  are  generally  similar,  or  at  any  rate,  if  they 
•20 


306  FOREIGN    BODIES    IN    THE    BLADDER. 

differ  at  all,  they  differ  only  in  a  very  slight  degree.  The  ex- 
traneous body  excites  cystitis  and  usually  becomes  incrustcd  in 
a  very  short  time  with  earthy  matter,  the  deposit  of  wliich  often 
proceeds  with  extraordinary  rapidity,  atul  sometimes  attains  a 
large  bulk  in  a  few  months.  The  deposit  is  generally  of  a  lithic 
or  phosphatic  nature;  in  rare  cases,  it  is  oxalic.  The  symptoms 
awakened  by  the  presence  of  the  intruder,  whatever  it  may  be, 
are  similar  to  those  which  characterize  stone  in  the  bladder. 
The  diagnosis  is  commonly  easily  established  by  the  history  of 
each  particular  case,  aided,  where  any  doubt  remains,  by  a  care- 
ful exploration  with  the  sound. 

A  long,  inflexible,  and  hard  foreign  body,  introduced  into  the 
bladder,  whether  designedly  or  otherwise,  will  occasionally  per- 
forate its  walls,  and,  escaping  into  the  peritoneal  cavity,  excite 
fatal  inflammation.  A  very  extraordinary  instance  of  this  nature 
occurred  in  Vermont,  in  the  practice  of  Dr.  Pond,'  in  a  man, 
flfty  years  of  age,  who  had  been  in  the  habit  of  indulging  in 
masturbation.  One  day,  he  introduced  a  leaden  bougie,  ten 
inches  in  length  by  three-quarters  of  an  inch  in  diameter,  and 
w^eighing  seventeen  ounces,  wdiich  inadvertently  slipped  from 
his  fingers,  and  passed  beyond  his  reach  along  the  urethra. 
Severe  suffering  was  the  result,  and  the  foreign  body  was  easily 
detected  in  the  bladder,  both  by  the  sound  ajid  by  the  finger  in 
the  rectum.  An  oi)eration  was  determined  upon,  but  before 
the  man  could  be  induced  to  submit  to  it,  the  bladder  gave  way, 
and  the  bougie  passed  into  the  abdomen.  Gastrotomy  being  at 
length  performed,  the  substance  was  found  to  be  entirely  lodged 
in  the  peritoneal  cavity,  having  escaped  from  the  bladder  through 
a  rent  in  its  posterior  wall.  For  a  while,  the  patient  seemed  to 
be  in  a  fair  way  of  recovery;  but,  at  the  end  of  the  ninth  day, 
he  became  unmanageable,  and  broke  open  the  wound,  and  died 
in  a  fortnight  after  the  occurrence  of  the  accident. 

When  the  extraneous  substance  is  small  it  may  be  expelled 
spontaneously.  Instances  are  recorded  by  Elscholtz,  Van  der 
Wiel,  Magnetus,  Stickney,  and  Lauderdale,  in  which  shot,  frag- 
ments of  iron,  or  balls,  were  suificiently  small  to  escape  through 
the  urethra.     A  bullet,  of  ordinary  size,  might  be  removed 

'  New  York  Jouru.  Med.  and  Surgery,  New  Series,  vol.  ix.  p.  10."). 


FOREIGN    BODIES    IX    THE    BLADDER. 


307 


Fiir. 


simply  by  dilating  the  urethra  ;  or,  this  failino;,  by  Cooper's 
forceps.  Dr.  H.  L.  W.  Burritt  has  reported  a  case  in  which, 
after  previous  dilatation  of  the  urethra,  a  piece  of  bougie,  three 
inches  in  le]igth,  was  expelled  bj^  the  projectile  force  of  a  full 
stream  of  urine,  retained  o\\\y  for  four  hours.  In  females,  rapid 
dilatation  with  the  finger,  or  with  the  instruments  already 
alluded  to,  while  the  patient  is  under  the  influence  of  chloroform, 
gives  ready  access  to  the  interior  of  the  bladder,  when  the  ex- 
traneous substance  may  be  removed  with  a  pair 
of  delicate  lithotomy  or  polypus  forceps. 

Many  cases  are  on  record  in  which  bits  of  elastic 
catheters  and  bougies  were  extracted  with  the  for- 
ceps, represented  in  fig.  88,  or  by  the  lithotrite. 
It  is  not  always  easy,  however,  to  seize  soft  cathe- 
ters, as  I  know  from  personal  experience.  In  a 
case  of  this  nature,  in  a  man,  sixty-three  years  of 
age,  I  was  obliged  to  make  the  median  incision  of 
lithotomy,  and  only  succeeded,  after  patient  efi:brts, 
in  extracting,  with  a  large  brass  bullet  probe,  bent 
at  nearly  a  right  angle,  a  Xo.  12  conical  bougie, 
which  was  curled  up  in  the  depression  behind  an 
enlarged  prostate  gland.  When  the  foreign  body 
is  a  pin  or  needle,  it  may  sometimes  be  entrapped 
in  the  eye  of  a  catheter,  as  in  the  memorable  case 
of  La  Motte. 

The  removal  of  pessaries,  introduced  either 
tlirough  mistake  or  design,  as  in  the  cases  recorded 
by  Storer,  Byford,  Edwards,  Woolen,  and  others, 
should,  if  possible,  be  effected  by  rapid  dilatation 
of  the  urethra,  combined,  if  it  be  found  necessary 
with  crushing  the  foreign  bod}'.  If  it  becomes 
indispensable  to  open  the  bladder  through  the 
vagina,  the  wound  should  be  at  once  closed  with 
wire  sutures. 

In  shot  wounds  of  the  bladder,  the  ball,  if  re- 
tained, generalh'  forms  the  nucleus  of  a  stone, 
while  bits  of  clothing  and  splinters  of  bone  are 
ordinarily  eliminated  by  the  urethra.     The  onl}'     F..rcepsf„i  Extract- 

,.„  T       •  ,      ,  ,  •  n       J  ,^  -I  iDg  Foreign  Bixiies 

1  emedy  is  cystotomy,  an  operation  first  pertormed      f,,„  „,e  madder. 


308  FOEEIGX    BODIES    IX    THE    BLADDER. 

by  Fr^re  Jacques,  io  1698.  Of  thirteen  cases  collected  by  Mr. 
Dixon,  of  London,'  ten  recovered  and  three  died.  .  During 
our  late  war  there  were  twenty-one  examples  of  lithotomy 
for  the  removal  of  concretions  consequent  upon  wounds  of  the 
bladder.  Of  these,  seventeen  recovered,  three  were  fatal,  and  in 
one  the  result  is  not  known.  Of  twelve  lateral  operations,  one 
died ;  of  three  suprapubic,  two  died ;  while  three  bilateral,  and 
two  median  operations  were  successful.  In  ten  cases  leaden 
bullets,  in  one  case  a  canister  shot,  in  one  a  fragment  of  a  grenade, 
in  one  an  arrow  head,  in  three  splinters  of  bone,  in  one  a  bit  of 
cloth,  in  one  a  tuft  of  hair,  in  one  inspissated  mucus,  and  in  one 
blood,  were  more  or  less  incrusted  wnth  phosphatic  deposits,  or 
formed  the  nuclei  of  large  calculi.^ 

In  an  exhaustive  paper  on  foreign  bodies  in  the  bladder,  M. 
Denuce,^  of  Bordeaux,  has  collected  125  cases  in  which  lithotomy 
was  resorted  to  for  their  removal.  In  males,  perineal  incisions 
were  practised  in  87  instances;  recto-vesical  in  2  ;  and  supra- 
pubic in  2 ;  in  females  urethral  or  vaginal  lithotomy  was  per- 
formed in  22,  and  the  high  operation  in  12.  In  only  61  of  the 
cases  is  the  result  given.  In  39  males,  perineal  lithotomy  was 
practised  in  36,  with  5  deaths,  epicystotomy  in  2,  both  of  which 
recovered,  and  recto-vesical  section  in  1,  which  terminated 
fatally.  In  22  females,  2  out  of  15  urethral  or  vaginal  opera- 
tions, and  5  out  of  7  hypogastric,  died.  Of  the  entire  number, 
therefore,  48  recovered,  and  13  died. 

'  Med.  Chir.  Tnins.,  vol.  xxxiii. 

2  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  Surgical  Volume,  Part 
ii.  pp.  262-303. 

3  ^loniteur  des  Hopitaux,  Nos.  126,  127,  and  128,  1856. 


CHAPTER   XII. 

WOUNDS  OF  THE  BLADDER. 

WouxDS  of  the  bladder  may  be  incised,  punctured,  contused, 
lacerated,  or  gunshot,  according  to  the  kind  of  weapon  with 
which  they  are  inflicted.  They  are  not  uncommon  in  military 
practice  ;  hut  it  is  interesting  to  note  that  there  was  not  a  single 
instance  of  a  punctured,  incised,  or  lacerated  wound  during  our 
late  war.  From  the  situation  of  the  viscus,  these  injuries  must 
always  necessarily  be  complicated  with  lesion  of  the  soft  parts 
by  which  it  is  surrounded,  and  also  not  infrequentl}^  with  frac- 
ture of  the  pelvic  bones. 

Incised  wounds  of  the  bladder  are  very  uncommon.  The  organ 
has  been  opened  accidentally  by  the  surgeon  when  it  formed  a 
hernial  protrusion  in  the  inguinal  or  femoral  regions,  as  in  the 
instance  which  happened  to  Roux.  Fodere  has  recorded  the 
case  of  a  man  who  plunged  a  knife  above  the  pubes  into  the  vis- 
cus, to  relieve  a  painful  retention  of  urine.  The  peritoneum  was 
not  inj  ured,  and  recovery  ensued.  The  prognosis  of  these  inj  uries 
is  far  worse  than  that  of  shot  or  other  lesions  of  the  bladder,  the 
majority  proving  fatal  from  infiltration  of  urine,  particularly 
when  the  peritoneum  is  involved,  within  forty-eight  hours. 

Punctured  wounds  are  usualW  produced  by  falls  upon  upright 
pieces  of  wood,  as  a  stake,  a  brush  handle,  or  the  broken  branch 
of  a  tree,  as  in  a  case  which  came  under  my  observation,  the 
foreign  substance  penetrating  the  bladder  through  the  perineum, 
the  abdominal  walls,  the  rectum,  or  vagina.  ISTotwithstanding 
their  apparently  desperate  nature,  these  injuries  are  frequently 
recovered  from  with  scarcely  any  treatment;  but  when  the 
vagina  or  rectum  is  implicated,  they  are  liable  to  be  folloAved 
by  fistule.  When  sinuses  refuse  to  close,  a  careful  examination 
will  show  that  the  discharge  is  kept  up  by  portions  of  tbe  clothing 
forced  into  the  bladder  at  the  time  of  the  accident,  or  by  broken 
oif  fragments  of  wood. 

Contused  Avounds  and  contusions  are  more  common  than  punc- 


310  WOUXDS    OF    THE    BLADDER. 

tured  and  incised  injuries,  and  are  generally  inflicted  by  blo\A's, 
falls,  or  the  pressure  of  the  foetal  head  in  protracted  labor,  or  the 
pressure  of  a  large  calculus  during  parturition,  through  which 
the  vesico-vaginal  septum  is  exposed  to  compression  both  from 
without  and  within.  As  a  natural  result  the  lower  wall  of 
the  bladder  and  the  anterior  wall  of  the  vagina  mortify,  and  a 
fistule  results.  Baron  Larrey  describes  the  case  of  a  soldier 
whose  bladder  was  contused  without  being  penetrated  by  the 
horn  of  a  bull,  and  formed  a  hernial  protrusion  beneath  Poupart's 
ligament. 

Lacerated  wounds  are  generally  inflicted  by  blows,  falls,  or 
kicks  upon  the  hypogastrium,  by  the  body  being  forcibly  jammed 
between  two  hard  and  resisting  objects,  by  the  instruments  em- 
ployed in  embryotomy,  as  in  a  case  mentioned  by  Sancerotte,  by 
the  forcible  use  of  the  catheter,  as  in  the  case  of  a  female  reported 
by  Berard,  and  by  the  lithotrite,  of  which  not  a  few  instances 
occurred  during  the  early  days  of  crushing,  either  through  the 
fault  of  the  operator,  or  the  bad  construction  of  the  instrument. 
These  injuries  usually  terminate  fatally. 

A  wound,  however  produced,  may  perforate  the  bladder,  or 
merely  pierce  one  of  its  walls ;  in  the  former  case,  there  will  be 
two  openings ;  in  the  latter,  only  one.  Again,  the  lesion  may 
involve  the  peritoneum,  or  it  may  take  place  in  front  and  below 
where  it  is  destitute  of  a  serous  investment,  circumstances  which 
have  an  important  influence  upon  the  prognosis  and  treatment 
of  the  accident. 

Shot  wounds  of  the  bladder,  although  less  fatal  than  punctured 
and  incised  wounds,  are  often  extremely  formidable,  destroj'ing 
the  patient  immediately  or  remotely,  producing  extensive  mis- 
chief among  the  soft  parts,  as  well  as  in  the  pelvic  bones,  and 
leading  to  the  formation  of  abscesses,  sinuses,  and  fistules,  which 
may  last  for  months  and  years,  and  render  life  utterly  miserable. 
When  the  ball  is  impelled  with  great  velocity,  it  will  be  apt  to 
enter  the  organ  at  one  point,  and  pass  out  directly  opposite  at 
another,  thus  leaving  two  apertures,  and  either  lodging  in  the 
neighborhood,  or  issuing  at  the  surface  of  the  body.  If,  on  the 
contrary,  it  move  slowly,  or  be  nearly  spent,  it  will  be  likely  to 
make  only  one  opening,  and  to  be  arrested  in  the  bladder,  from 
which  it  may  ultimately  be  discharged  by  the  urethra,  or  by  a 
fistulous  passage ;    or,  what   is  more  probable,  it  will  become 


WOUNDS    OF    THE    BLADDER. 


Bll 


inerusted  with  earthy  matter,  and  thus  form  the  nucleus  of  a 
calcuhis.  Instead  of  etfecting  direct  penetration,  the  missile  may 
enter  by  ulcerative  absorption,  as  occurred  in  seven  of  the  thirteen 
cases  of  removal  of  projectiles  during  our  late  war.  In  several 
examples,  narrated  by  Larre}^,  the  ball  was  lodged  in  the  walls  of 
the  viscus,  partly  without  and  partly  within  its  cavity  ;  and  he 
ascribes  non-penetration  to  the  loss  of  momentum  of  the  pro- 
jectile, to  the  sudden  contraction  of  the  bladder,  and  to  the 
resistance  ottered  by  the  urine  it  may  contain.  The  lesion  is 
often  complicated  with  fracture  of  the  pelvic  bones,  injury  of 
the  large  vessels,  and  perforation  of  the  rectum,  as  in  fig.  89,  the 

Fisr.  89. 


Shot  Perfoiation  of  the  Bladder  and  Rectum. 


small  intestines,  the  uterus,  the  vagina,  or  the  genital  organs.  In 
the  former  case,  serious  mischief  is  sometimes  done  by  the  osseous 
splinters  which  the  ball  makes  and  detaches  in  its  course  towards 
the  bladder,  and  which  not  infrequently  tind  their  way  into  the 
interior  of  this  organ,  where  they  maj-  give  rise  even  to  more 
disastrous  consequences  than  tiie  ball  itself.  Wadding,  pieces 
I  of  cloth,  or  portions  of  the  patient's  attire,  may  accompany  the 
ball,  and  be  temporarily  or  permanently  retained  in  the  bladder. 
In  a  gunshot  wound,  the  danger  of  extravasation  is  not  always 
primary,  but  sometimes  secondary.  The  ball  may  have  penetrated 
the  coats  of  the  organ  obliquely  or  in  a  sort  of  valvular  manner, 


312  WOUNDS    OF    THE    BLADDER. 

or  it  may  have  been  unusually  small.  In  either  of  these  eases, 
the  urine  may  not  escape  at  all,  or  the  occurrence  may  he  post- 
poned until  the  separation  of  the  sloughs.  This  will  usually 
happen  at  some  period  from  the  seventh  to  the  twelfth  day,  and 
during  this  time  the  patient  should  be  closely  watched,  otherwise 
serious,  if  not  fatal,  mischief  may  be  the  result. 

It  has  been  already  stated  that  the  ball,  if  lodged  in  the  bladder, 
is  variously  disposed  of.  In  the  generality  of  cases,  it  soon  be- 
comes incrusted  with  earthy  matter,  which  gradually  increases 
in  quantity  until  a  considerable-sized  calculus  is  the  result,  pro- 
ducing all  the  symptoms  of  a  common  concretion,  and  requiring, 
perhaps,  the  operation  of  lithotomy  for  its  removal.  More  rarel}', 
the  ball  causes  ulcerative  absorption,  and  is  finally  discharged 
through  the  perineum,  or  the  rectum ;  usually  the  latter,  since 
it  always  has  a  tendency  to  fall  into  the  bas-fond  of  the  bladder. 
It  is  possible  that  the  foreign  body  may  become  encysted,  without 
producing  any  decided  symptoms.  When  the  ball  is  very  small, 
it  may  escape  externally  through  the  m-ethra,  of  which  occurrence 
several  instances  are  mentioned  in  the  preceding  chapter. 

Pieces  of  wadding,  of  cloth,  and  of  bone,  introduced  into  the 
bladder,  either  alone,  or  in  union  with  the  ball,  are  ordinarily 
discharged  through  the  urethra.  Sometimes,  however,  they  are 
retained,  and  form  the  nucleus  of  a  calculous  concretion. 

Wounds  of  the  bladder,  however  small  or  insignificant,  are 
amongst  the  most  dangerous  accidents  to  which  a  human  being 
is  exposed.  It  was  formerly  considered  that  all  such  lesions  were 
necessarily  fatal  within  a  short  period  of  their  occurrence. 
Modern  observation,  however,  has  long  since  disproved  the 
validity  of  this  conclusion,  by  showing  that  recoveries  are  by  no 
means  infrequent,  and  that,  too,  under  circumstances  apparently 
the  most  desperate.  Of  183  cases  of  shot  wounds  that  occurred 
during  our  late  war,  87,  or  47.5  per  cent.,  survived,  although  a 
large  majority  suffered  from  serious  disabilities  and  infirmities. 
In  7  cases  there  was  persistent  urinary  fistule,  from  the  presence, 
in  most  instances,  of  dead  bone ;  13  patients  recovered  with 
recto-vesical  fistule ;  17  survived  the  operation  of  lithotomy  for 
the  removal  of  concretions  consequent  upon  the  injury  ;  while 
examples  of  cure  with  the  functions  of  the  bladder  completely 
restored  were  rare.  In  the  majority  of  the  fatal  cases,  one  or 
more  of  the  pelvic  bones  were  fractured,  and  the  most  frequent 


WOUNDS    OF    THE    BLADDER.  313 

cause  of  death  was  urinary  infiltration,  giving  rise  to  peritonitis 
or  diffuse  cellulitis,  and  followed  by  septicemia  or  pyemia. 

The  circumstances  favorable  to  recovery  are  a  small  opening, 
and  oblique  penetration  of  the  cavity  of  the  bladder,  the  viscus 
being  at  the  same  time  nearly  or  quite  empty,  through  which 
the  risk  of  effusion  of  urine  is  greatly  diminished. 

A  wound  involving  a  part  of  the  bladder  that  is  uncovered 
by  peritoneum,  is  less  dangerous  than  one  in  which  this  mem- 
brane is  injured.  The  urine  in  the  former  case  escapes  into  the 
subserous  connective  tissue,  where,  although  it  may  awaken 
severe  inflammation,  followed,  perhaps,  b}'  abscess  or  gangrene, 
it  is  less  deleterious  than  when  it  finds  its  way  into  the  general 
cavity  of  the  abdomen,  where  its  presence  almost  invariably 
causes  death  in  a  few  days.  The  experience  of  our  late  war 
teaches  tliat  such  injuries  heal  readily,  provided  the  bladder  be 
kept  at  rest  by  affording  a  free  exit  for  the  urine.  Hence,  a 
wound  of  the  inferior  part  of  the  bladder  is  less  likely  to  prove 
serious  than  one  affecting  the  body  or  fundus  of  the  organ,  par- 
ticularly if  made  with  the  spherical  ball.  Thomson  met  with 
not  less  than  14  cases  of  this  kind  after  the  battle  of  Waterloo, 
and  Guthrie  refers  to  6  similar  examples.  Larrey,  who  saw  a 
number  of  instances  of  gunshot  wounds  of  the  bladder  in  Egypt 
and  Syria,  states  that  thej^  generally  terminated  well.  That 
wounds  inflicted  by  cylindro-eonoidal  projectiles  do  not  always 
cause  death  is  attested  by  the  fact  that  of  10  examples  which 
occurred  during  our  late  war  of  the  removal  of  projectiles,  in- 
crusted  Avith  phosphates,  or  forming  the  nuclei  of  large  stones, 
from  the  bladder,  only  3  were  round,  while  7  were  conical. 

The  symptoms  of  this  lesion  are,  the  existence  of  an  opening 
in  the  lower  p)art  of  the  hypogastric  region,  the  groin,  or  the 
perineum  ;  sudden  and  acute  pain  in  the  situation  of  the  affected 
organ,  extending  along  the  urethra,  and  often  accompanied  by 
sliglit  priapism  ;  an  escape  of  urine,  or  urine  and  blood,  at  the 
external  wound ;  frequent  but  inefiectual  attempts  at  micturi- 
tion ;  violent  tenesmus ;  and  a  discharge  of  blood  from  the  ure- 
thra. The  system  labors  under  all  the  oflects  of  a  violent  shock. 
I  The  countenance  is  pale  and  ghastly,  the  breathing  is  hurried 
and  oppressed,  the  pulse  is  small  and  feeble,  the  stomach  is 
nauseated,  and  the  surface  is  covered  Avith  a  cold,  clammy  per- 
spiration.    When  the  injury  is  complicated  with  perforation  of 


314  AVOUXDS    OF    THE    BLADDER. 

the  bowel,  fecal  matter,  mucus,  bile,  or  gas,  mixed  with  urine, 
or  urine  and  blood,  may  issue  both  at  the  external  opening  and, 
at  the  urethra.  "When  the  pelvic  cavity  is  pierced,  the  state  of 
collapse,  the  usual  consequence  of  the  accident,  is  speedily  fol- 
lowed by  symptoms  of  peritonitis,  of  which  the  patient  almost 
always  dies  in  two  or  three  days.  AVhen  the  bladder  is  wounded 
through  the  perineum  or  above  the  pubes,  at  a  jtoint  where  it  is 
uncovered  by  serous  membrane,  urinary  infiltration  is  liable  to 
take  place,  and  the  probability  of  the  occurrence  will  be  so  much 
the  greater  if  the  external  opening  is  disproportionately  small,  if 
the  track  of  the  wound  is  narrow  and  devious,  and  if  the  organ 
was  much  distended  at  the  time  of  the  accident. 

The  discharge  of  urine  at  the  external  wound  may  be  momen- 
tary, or  it  may  last  for  a  considerable  period.  It  is  sometimes 
continued  ;  but  for  the  most  part  it  is  intermittent,  and  exceed- 
ingly irregular  in  regard  to  its  quantity.  In  some  instances,  all 
the  urine  escapes  by  the  external  wound,  especially  if  this  be 
situated  in  the  perineum  or  in  the  rectum. 

In  tlie  treatment  of  a  wounded  bladder,  two  prominent  indi- 
cations are  presented:  first,  to  prevent  extravasation  of  urine; 
and,  secondly,  the  occurrence  of  undue  inflammation. 

Unfortunately,  the  first  of  these  accidents  often  takes  place  at 
the  moment  of  the  injury,  and  consequently  before  the  surgeon 
has  an  opportunity  of  interfering.  When  the  bladder  is  dis- 
tended, it  matters  not  where  it  is  laid  open,  whether  at  a  part 
invested  b\^  peritoneum  or  not,  effusion  of  urine  will  be  inevita- 
ble. When  the  general  cavity  of  the  abdomen  is  penetrated,  the 
contact  of  the  fluid  will  in  a  few  hours  set  up  intense  peritonitis, 
which  is  usually  bej'ond  control.  The  disease  proceeds  in  spite 
of  the  best  directed  eftbrts  to  combat  it.  This  being  the  fact, 
the  patient's  only  chance  consists  in  preventing  its  occurrence. 
This  is  to  be  attempted  by  attention  to  position,  and  by  the 
instant  evacuation  of  the  bladder.  The  patient  should  be  placed 
almost  semierect  in  bed,  and  an  elastic  catheter  with  an  opening 
in  its  point  should  be  left  in  the  bladder,  where  it  is  to  be  secured 
in  the  usual  manner,  to  enable  the  urine  to  pass  ott"  as  fast  as  it 
is  secreted.  In  a  word,  the  organ  should  be  kept  constantly 
empt}'  and  quiet  for  the  first  fifteen  or  twenty  days,  or  until 
there  is  reason  to  conclude  that  the  wound  is  closed,  and  all  risk 
of  infiltration  over.     When  extravasation  has  actuallv  occurred, 


WOUNDS    OF    THE    BLADDER.  315 

the  bladder  should  he  opened  through  the  perineum,  as  suggested 
in  the  succeeding  chapter. 

The  development  of  undue  inflammation  is  to  he  prevented  by 
the  employment  of  antiphlogistic  means.  Foremost  amongst 
these  are  general  and  local  bleeding,  calomel  and  opium,  and  hot 
fomentations  to  the  abdomen.  Anodynes  must  be  given  in  full 
and  sustained  doses,  both  by  the  mouth  and  by  the  rectum,  to 
allay  pain  and  spasm  of  the  bladder,  induce  sleep,  and  diminish 
the  renal  secretion.  The  drinks  must  be  cooling  and  demulcent, 
but  not  abundant;  the  diet  must  be  perfectly  light  and  bland, 
and  the  bowels  must  be  disturbed  as  little  as  possible  during 
the  first  fortnight.  Abscesses,  the  result  of  urinary  infiltration, 
are  to  be  opened  by  early  and  free  incisions. 

N^othing  can  be  gained  by  an  attempt  to  extract  the  foreign 
body,  when  the  injur}^  has  been  produced  by  firearms;  for  the 
very  moment  it  is  inflicted  the  urine  escapes,  and  the  bladder 
contracts  upon  itself  so  as  to  destroy  the  relations  between  the 
external  and  internal  wounds.  If  the  ball  has  fallen  into  the 
bladder,  it  may,  if  not  too  large,  either  pass  off  spontaneously, 
or  be  removed  with  the  forceps ;  should  it  be  otherwise,  and 
severe  symptoms  be  caused  by  its  presence,  it  must  be  cut  out 
through  the  perineum  by  an  operation  similar  to  that  of  median 
lithotom3\  This  may  be  done  immediately  or  within  a  short 
period  after  the  accident,  if  the  ball  has  entered  beneath  the 
pubes,  for  the  reason  that  the  organ  will  not  only  be  freed 
thereby  of  a  disagreeable  intruder,  but  also  because  there  will 
be  less  risk  of  urinary  infiltration. 


CHAPTER    XIII. 

RUPTURE  OF  THE  BLADDER. 

The  urinary  bladder,  like  the  other  hollow  viscera,  is  liable 
to  rupture,  from  overdistention,  or  from  external  violence. 
When  the  laceration  takes  place  as  a  consequence  of  the  inor- 
dinate accumulation  of  urine  from  paralysis  of  the  muscular 
fibres  of  the  bladder,  hypertrophy  of  tlie  prostate  gland,  or 
obstruction  of  the  urethra,  there  is  almost  always  some  degree 
of  softening  of  the  diflerent  coats  of  the  organ,  thus  predis- 
posing them  to  this  occurrence.  In  such  a  case,  it  is  only 
necessary  for  the  patient  to  use  some  unusual  or  sudden  ex- 
ertion, such  as  sneezing,  vomiting,  or  straining  at  stool  or 
micturition,  to  produce  the  ettcct  in  question.  The  pressure  of 
the  diaphragm  and  the  abdominal  muscles  under  such  circum- 
stances upon  the  overdistended  viscus,  is  equivalent  to  a  tolerably 
severe  blow,  kick,  or  fall  upon  the  hypogastric  region,  the  most 
common  cause  of  the  accident  when  it  results  from  external 
injury.  A  similar  predisposition  is  sometimes  established  by 
the  ulcerative  process,  and  by  excessive  inflammatory  action, 
eventuating  in  partial  gangrene.  The  laceration  when  thus 
produced  usually  occurs  at  the  bas-fond  of  the  bladder,  and  is 
generally  of  small  extent. 

But  the  most  common  cause  of  the  accident  is  external 
violence,  and  it  is  worthy  of  remark,  both  in  a  surgical  and  a 
medico-legal  point  of  view,  that  it  may  occur  from  the  most 
trivial  injur}-.  Any  force  suddenly  applied  to  the  hypogastric 
region,  as  a  smart  blow,  a  kick,  or  a  fall,  Avill  frequently  suffice 
to  produce  it.  For  the  force,  however,  to  be  eff'ective,  it  is 
necessary  that  the  bladder  should  be  distended  at  the  time  of 
the  accident.  If  it  is  empty,  or  only  partially  filled  with. urine, 
the  blow,  unless  directed  with  great  precision,  will  be  inopera- 
tive. The  rupture  most  commonly  occurs  in  brawls,  in  which 
the  individual,  generally  under  the  influence  of  liquor,  receives 
the  weight  of  the  body  of  his  antagonist  upon  his  abdomen,  or 


RUPTURE  OF  THE  BLADDER.  317 

in  whicli  this  part  is  struck  with  the  head,  hand,  elbow,  foot,  or 
knee.  It  may  also  be  caused  by  a  fall  from  a  considerable  height, 
by  the  pelvis  being  jammed  between  two  hard  and  resisting 
objects,  as  a  wall  and  the  wheel  of  a  carriage,  or  by  striking  the 
hypogastrium  against  a  post,  a  stone,  or  the  corner  of  a  table. 
The  accident  may  occur  in  females  during  parturition,  in  con- 
sequence of  the  pressure  of  the  child's  head,  when  the  patient 
has  neglected  to  empty  the  bladder ;  and  it  occasionally  happens 
from  overdistention  of  the  viscus,  consequent  upon  retroversion 
of  the  uterus ;  or  during  the  attempts  which  are  necessary  to 
restore  the  dislocated  organ  to  its  natural  position. 

The  age  of  the  patient  does  not  appear  to  exert  any  marked 
influence  upon  laceration  of  the  bladder  from  mechanical  causes, 
whether  these  causes  act  through  the  abdominal  parietes,  through 
the  uterus,  or  through  the  pelvic  bones.  Laceration  depending 
upon  overdistention  of  the  bladder  is  most  common  in  old  sub- 
jects, in  whom  the  powers  of  life  have  been  enfeebled  by  pro- 
tracted suffering,  and  is  usually  associated  with  softening,  and 
attenuation  of  the  different  tunics  of  the  oro;an.  King;,^  How- 
ship,^  and  Malgaigne,^  have  each  published  a  case  of  the  accident 
as  occurring  in  the  foetus.  The  lesion,  from  both  causes,  is,  for 
obvious  reasons,  more  common  in  males  than  in  females. 

When  caused  by  external  violence,  the  accident  may  be  com- 
plicated with  fracture  of  the  pelvic  bones,  laceration  of  some  of 
the  parenchymatous  organs,  as  the  spleen,  liver,  or  kidney,  and 
injury  of  the  vessels,  attended  with  internal  hemorrhage.  It  is 
worthy  of  notice,  especially  in  a  medico-legal  point  of  view,  that 
it  may  occur  without  any  mark  of  violence  upon  the  surface.  In 
many  cases,  however,  there  is  more  or  less  contusion  with  ecchy- 
mosis  of  the  skin,  connective  tissue,  and  muscles  of  the  hypo- 
gastric region,  and  scfmetimes  also  of  the  pubes  and  perineum. 

The  rent  may  be  perpendicular,  oblique,  or  transverse.  Its 
edges  are  uneven,  ragged,  and  everted.  In  some  instances  it  is 
considerably  diminished  in  size  by  a  protrusion  of  the  mucous 
membrane ;  and  now  and  then  it  looks  as  if  it  had  been  made 
with  a  punch  or  sharp  instrument.     In  extent  it  varies  from  a 

'  Guy's  Hospital  Reports,  ii.  p.  510. 

2  Op.  cit. 

3  Yidal,  Traite  de  Pathol.  Extenie,  t.  v.  Sec.  ed. 


318  RUPTURE    OF    THE    BLADDER. 

few  lines  to  several  inches,  being  at  one  time  so  small  as  hardly 
to  admit  a  common-sized  qnill,  and  at  another  so  large  as  to 
receive  a  small  fist.  Several  lacerations  occasionally  exist,  but 
usually  there  is  only  one.  There  is  no  regularity  in  regard  to 
the  seat  of  the  lesion.  It  is  most  common,  however,  in  the 
posterior  wall  of  the  bladder,  next  in  the  anterior  wall,  then 
at  the  fundus,  and  lastly  at  tlio  bas-fond.  The  neck  also  some- 
times suffers ;  and  cases  occur  in  which  the  viscus  is  literally 
torn  from  its  attachments  to  the  pelvic  bones.  Of  87  cases  due 
to  external  violence,  collected  by  Houel,'  15  involved  the  pos- 
terior wall  and  12  the  anterior  wall,  3  the  sides,  and  2  the 
summit ;  3  were  double,  and  in  2  the  situation  is  not  stated. 
Traumatic  rupture  of  the  posterior  wall  nearly  always  extended 
through  the  peritoneum,  whereas,  in  the  other  situations,  this 
membrane  generally  remained  intact.  Of  7  spontaneous  rup- 
tures, on  the  other  hand,  the  posterior  wall  was  involved  in  5, 
and  the  bas-fond  in  2 ;  and  it  is  noteworthy  that  the  peritoneum 
remained  intact  in  all.  Of  78  cases  analyzed  in  1851,  by  Dr. 
Stephen  Smith,^  the  posterior  wall  suffered  in  50,  the  anterior 
wall  in  9,  and  the  neck  in  6.  The  peritoneal  investment  may 
be  involved  in  the  rent,  or  this  membrane  may  retain  its  in- 
tegrity, and  all  the  other  coats  give  way.  In  tliis  way  the 
lesion  may  be  partial  or  complete.  In  the  former  variety,  the 
urine,  instead  of  escajdng  into  the  pelvic  and  abdominal  cavities, 
is  extensively  infiltrated  into  the  subserous  connective  tissue  of 
the  pelvis,  and  of  the  abdominal  muscles,  and  the  peritoneum, 
at  the  seat  of  the  lesion,  bulges  out  in  the  form  of  a  small  trans- 
lucent pouch. 
,  The  accident  usually  reveals  itself  by  well-marked  symptoms, 
both  general  and  local.  Violent  pain  is  instantly  experienced 
in  the  hy^iogastric  region,  the  face  is  pale  And  ghastly,  the  pulse 
is  small,  rapid,  and  fluttering,  the  respiration  is  hurried  and 
difficult,  the  extremities  are  cold,  and  the  surface  is  covered 
with  a  clammy  perspiration.  The  patient  occasionally  falls 
down  in  a  state  of  insensibility,  as  if  he  had  been  struck  on  the 
head  or  stomach;  but  this  is  not  always  the  case ;  for  sometimes 
he  is  able  to  walk  about,  and  perhaps  go  some  distance  before 

'  Des  Plaies  et  des  Ruptures  de  la  Vessie,  Paris,  1857,  pp.  64  and  G8. 
2  New  York  Jouru.  of  Med.  and  Surg.,  N.  S.,  vol.  vi.  p.  374. 


RUPTURE    OF    THE    BLADDER.  819 

bad  sjmiptoms  appear.  Xot  infrequently  he  feels  as  if  somethino- 
had  burst  or  given  way  in  his  abdomen,  attended,  perhaps,  with 
a  crack,  or  audible  noise.  In  nearly  all  cases  there  is  a  constant 
desire  to  urinate,  and  an  inability  to  pass  a  single  drop  of  water. 
A  small  quantity  of  blood  often  flows  by  the  urethra.  These 
symptoms  are  soon  followed  by  nausea  and  vomiting,  intense 
thirst,  excessive  restlessness,  and  an  expression  of  intensive 
suffering,  with  swelling  and  tenderness  of  the  abdomen.  The 
period  of  collapse  may  last  from  a  few  minutes  to  several  hours 
or  even  days,  and  the  patient  may  die  from  the  shock  of  tlie 
system,  or  reaction  may  occur,  and  he  may  perish  from  the 
effects  of  peritonitis. 

The  introduction  of  the  catheter  is  generally  followed  by  a 
flow  of  Ijloody  or  turbid  urine,  and  not  infrequently  l)y  blood 
alone,  either  fluid  or  partly  fluid  and  partly  coagulated.  The 
instrument  enters  without  difficulty,  and  the  point  sometimes 
passes  through  the  rent  of  the  bladder  into  the  peritoneal  cavity, 
where  it  may  be  made  to  move  about  in  difterent  directions, 
and  even  be  felt  by  the  finger  across  the  walls  of  the  abdomen. 

Of  these  symptoms,  the  most  worthy  of  reliance,  in  a  diag- 
nostic point  of  view,  because  the  most  constant,  are  the  sudden 
pain  in  the  hypogastric  region,  a  frequent  but  fruitless  effort  to 
urinate,  an  escape  of  blood  by  the  urethra,  the  inability  of  the 
surgeon  to  relieve  the  bladder  with  the  catheter,  and  the  rapid 
collapse  of  the  system.  The  sensation  of  tearing,  or  giving  way, 
is  often  absent,  and  so  is  also  the  crack  or  audible  noise.  The 
character  of  the  pain  is  not  to  be  disregarded.  It  always  comes 
on  at  the  moment  of  the  laceration,  and  is  generally  so  violent 
as  to  induce  extreme  faintness  with  all  the  other  symptoms  of 
prostration.  It  may  be  sharp  or  lancinating,  hot  or  burning, 
colicky  or  cramp-like.     The  symptoms  uoav  enumerated,  added 

!  to  the  history  of  the  case,  leave  no  doubt  in  regard  to  the  nature 

'  of  the  lesion. 

[  In  laceration  of  the  bladder  external  to  the  peritoneum,  or  in 
the  partial  variety  of  the  afl'ection,  the  symptoms  are  equally 

[  severe  in  the  first  instance,  but  the   reaction  generally  takes 

j  place  sooner,  and  there  is  a  longer  interval  between  it  and  the 
occurrence  of  peritonitis.  The  pain  during  this  period  is  less 
violent,  the  abdomen  is  not  so  tender  under  pressure,  the  pulse 


320  RUPTUKE    OF    THE    BLADDER. 

is  not  SO  much  depressed,  and  there  is  less  prostration  of  strength. 
More  urine,  too,  flows  hy  tlie  catheter. 

The  state  of  collapse,  having  continued  for  some  time,  is  at 
length  followed  hv  a  certain  amount  of  reaction,  which  is  itself 
speedily  succeeded  by  symptoms  of  peritonitis.  The  counte- 
nance now  becomes  flushed,  the  skin  is  hot  and  dry,  the  pulse 
is  small,  quick,  and  wiry,  the  belly  is  tympanitic  and  exquisitely 
tender  on  pressure,  the  limbs  are  drawn  up  to  relax  the  abdomi- 
nal muscles,  the  respiration  is  quick  and  hurried,  and  the  patient 
is  often  delirious  at  an  early  period  of  the  attack.  By  and  by, 
hiccup  sets  in  with  bilious  vomiting,  the  pulse  fails  at  the  wrist, 
the  surface  is  bathed  with  a  cold,  clammy  sweat  of  a  urinous 
odor,  the  countenance  becomes  Ilippocratic,  and  the  patient  falls 
into  a  state  of  coma,  under  which  he  gradually  expires. 

On  dissection,  the  ruptured  organ  is  usually  found  to  be  very 
much  contracted,  and  hardly  ever  contains  more  than  a  few 
drachms  of  urine.  In  some  instances,  especially  in  the  partial 
varieties  of  the  lesion,  it  is  considerably  dilated,  from  the  pre- 
sence of  coagulated  blood. 

The  edges  of  the  rent  are  generally  ragged,  sloughy,  and  of  a 
deep  rod  or  purple  color  ;  and  the  lining  membrane  of  the  organ 
exhibits  evidence  of  high  inflammatory  action.  All  the  tunics, 
in  fact,  are  frequently  softened,  and  altered  in  their  appearance. 
The  surface  of  the  bladder  is  incrusted  with  lymph,  and  united 
to  the  neighboring  parts ;  the  intestines  adhere  to  each  other; 
the  peritoneum  is  highly  injected,  and  of  a  deep  red  color;  and 
the  abdominal  cavity  contains  more  or  less  urine  mixed  with 
serum,  lymph,  and  blood.  In  protracted  cases,  there  is  some- 
times, in  addition  to  these  fluids,  an  eti'usion  of  pus.  The 
quantity  of  urine  present  may  be  very  small,  or  it  may  amount 
to  several  quarts.  The  same  remark  applies  to  the  accumulated 
blood.  When  death  occurs  soon  after  the  accident,  neither  the 
bladder  nor  the  peritoneum  exhibits  any  marked  evidence  of 
inflammation.  In  partial  rupture,  the  subserous  connective 
tissue  of  the  bladder,  of  the  pelvic  cavity,  and  of  the  abdominal 
muscles,  is  gangrenous,  and  infiltrated  with  urine;  the  perito- 
neum is  highly  inflamed  ;  the  bladder  is  softened  and  discol- 
ored ;  and  the  abdominal  cavity  contains  more  or  less  serum  and 
lymph. 

Sometimes  the  inflammation  is  limited  to  the  neighborhood 


RUPTUEE    OF    THE    BLADDER.  321 

of  the  bladder,  and  an  effort  is  made  by  natnrc  to  repair  the 
injury  by  an  abundant  eff'usion  of  lympli.  In  this  manner  a 
sort  of  adventitious  sac  may  be  formed,  in  which  the  urine,  or 
the  urine  and  blood,  may  accumulate,  and  thus  be  prevented 
from  inducing  fatal  peritonitis. 

Laceration  of  the  bladder  is  nearly  always  fatal.  Indeed, 
there  are,  so  far  as  I  know,  not  more  than  eight  cases  of  recovery 
from  this  injury  upon  record.  Death  usually  takes  place  within 
the  first  five  days  after  the  occurrence  of  the  accident.  It  may, 
however,  be  postponed  until  a  later  period ;  and  a  case  is  men- 
tioned by  Dr.  E.  R.  Peaslee^  where  the  patient,  a  man,  aged 
thirty  years,  survived  forty-two  days.  The  laceration  w^as  situ- 
ated at  the  neck  of  the  bladder,  and  was  complicated  with 
wound  of  the  perineum  and  fracture  of  the  pelvic  bones.  Large 
abscesses  were  found  in  both  iliac  regions  after  death. 

The  immediate  source  of  danger  from  laceration  of  the  blad- 
der is  the  poisonous  effect  which  the  urine  exerts  upon  the 
nervous  system,  and  which,  together  wdth  the  excruciating  pain, 
appears  to  be  the  cause  of  the  collapse  into  which  the  patient  so 
frequently  falls  almost  at  the  moment  of  the  accident.  The 
depression  and  suffering  may  be  so  great  as  to  occasion  death  in 
a  few  minutes,  or,  at  furthest,  in  a  few  hours. 

Another  source  of  danger  is  the  consequent  hemorrhage,  which 
is  profuse  in  proportion  to  the  extent  of  the  laceration,  and  the 
size  of  the  injured  vessels.  When  the  accident  is  complicated 
with  fracture  of  the  pelvic  bones,  a  large  artery  or  vein  may  be 
implicated,  and  the  individual  may  speedily  sink  from  exliaus- 
tion.  The  amount  of  hemorrhage  cannot  be  estimated  by  the 
quantity  of  blood  which  escapes  by  the  urethra ;  the  bleeding 
goes  on  internally,  and  the  fluid  collects  in  the  bladder  or  pelvic 
cavity.  When  the  blood  exists  in  large  quantity,  and  in  a  solid 
state,  it  may  form  a  hard  tumor,  which  can  be  easily  felt  by  the 
hand  upon  the  abdomen  or  the  finger  in  the  rectum. 

In  an  elaborate  and  valuable  monograph  to  which  reference 
has  alread}^  been  made.  Dr.  Stephen  Smith  has  analyzed  seventy- 
eight  cases  of  rupture  of  the  bladder,  reported  by  different  ob- 
servers.    Of  these  sixty-seven  w^  ere  males  and  eleven  females ; 

'  Amer.  Jouiual  Med.  Sciences,  N.  S.  vol.  xi.\-,  p.  dSo. 
21 


322  RUPTURE    OF    THE    BLADDER. 

making  the  proportion  of  the  former  to  the  latter  nearl}'  as  six 
to  one.  Three  were  under  ten  years  of  age  ;  three  between  ten 
and  twenty ;  nineteen  between  twenty  and  thirty ;  twenty-six 
between  thirty  and  forty ;  seven  between  forty  and  fifty ;  and 
four  between  fifty  and  sixty.  The  ages  of  the  other  patients, 
who  were  adults,  are  not  given. 

The  cause  of  the  accident  was  direct  violence  in  forty-eight  of 
the  cases ;  in  fifteen,  concussion  of  the  body ;  in  four,  parturi- 
tion ;  in  one,  retroversion  of  the  uterus ;  and  in  four,  stricture 
of  the  urethra.  In  the  remainder  of  the  cases,  the  nature  of  the 
cause  is  not  specified. 

The  primary  symptoms  are  stated  to  have  been  severe  in  fifty- 
nine  of  the  cases,  and  it  is  worthy  of  note  that  in  forty-three  of 
these  the  rupture  extended  into  the  peritoneal  cavity.  In  nine, 
of  which  seven  likewise  atfected  the  peritoneal  cavity,  the  symp- 
toms were  slight,  and  in  three  they  were  entirely  absent.  In 
twenty-eight  of  the  cases,  there  was,  from  the  beginning,  ina- 
bility to  urinate;  in  three,  on  the  contrary, the  bladder  retained 
its  expulsive  power.  Bloody  urine  was  drawn  in  twenty-five 
cases,  and  clear  urine  in  four.  In  seven  of  the  cases,  the  patients 
were  able  to  walk  after  the  occurrence  of  the  injury.  Seven  of 
the  patients  felt  a  sensation  at  the  moment  of  the  accident  as  of 
the  bladder  bursting. 

In  fifty  of  the  cases,  the  rupture  affected  the  cavity  of  the 
peritoneum,  thirty-nine  being  caused  by  direct  violence,  six  by 
concussion  or  indirect  violence,  four  by  parturition,  two  by 
stricture  of  the  urethra,  and  one  by  retroversion  of  the  uterus. 
In  nine  of  the  cases,  the  rent  existed  in  the  anterior  wall  of  the 
bladder;  of  these,  five  were  induced  by  external  injury,  one  by 
stricture,  and  three  by  concussion.  Rupture  of  the  neck  of  the 
organ  was  present  in  six  cases,  in  five  of  which  it  was  caused  by 
direct  violence.  In  seventeen  of  the  cases,  the  bladder  was 
firmly  contracted,  and  in  two  it  was  not  discovered  on  the  dis- 
section of  tlie  body.  In  thirty-four  of  the  cases,  in  twenty-seven 
of  which  the  laceration  involved  the  peritoneum,  there  were 
marks  of  inflammation  in  the  abdomen,  while  in  seven  no  lesion 
of  the  kind  was  detected.  Fracture  and  injury  of  the  pelvis 
existed  in  fifteen  cases.  In  nearly  all  there  was  an  absence  of 
evidence  of  external  violence. 


RUPTURE  OF  THE  BLADDER.  323 

Of  tlie  seventy-eight  patients  seventy-three  died;  forty-four 
within  the  first  five  days,  twenty-two  between  five  and  ten  days, 
two  between  ten  and  fifteen  days,  three  between  fifteen  and 
twenty  days,  one  above  twenty  days,  and  one  at  the  end  of 
forty-two  days.  In  those  who  died  soonest,  and  they  constituted 
the  great  majority,  the  rent  extended  into  the  peritoneal  cavity. 
In  the  five  patients  that  recovered,  the  lesion,  in  one,  was 
partial,  in  one  it  involved  the  peritoneal  cavity,  and  in  three  it 
extended  into  the  connective  tissue.  v 

In  the  treatment  of  this  lesion,  our  efforts  must  be  directed, 
first,  to  affording  a  free  outlet  for  the  urine  as  rapidly  as  it  is 
secreted  as  well  as  for  that  already  extravasated,  and  preventing 
its  further  diffusion  into  the  surrounding  structures ;  and, 
secondly,  to  arresting  or  controlling  the  resulting  peritonitis  or 
pelvic  cellulitis. 

To  fulfil  the  first  indications,  if  the  surgeon  is  satisfied  that 
the  posterior  wall  of  the  bladder  is  the  seat  of  the  laceration,  and 
that  there  is  an  accumulation  of  fluid  in  the  recto-vesical  cul-de- 
sac,  as  denoted  by  a  fluctuating  swelling  in  that  locality,  relief 
might  be  afforded  by  the  rectal  puncture,  as  originally  suggested 
by  Dr.  Harrison,'  as  the  tendency  of  the  urine  is  to  subside  into 
that  fold  of  the  peritoneum.  Since,  however,  it  is  by  no  means 
easy  to  determine  the  situation  of  the  rupture,  this  expedient  is 
as  liable  to  eventuate  in  failure  as  in  success  ;  and  as  it  would, 
at  the  best,  merely  give  egress  to  the  fluid  extravasated  at  the 
time  of  the  accident,  and  not  prevent  its  further  eff'usion,  it  is  a 
remedy,  in  my  judgment,  entitled  to  little  confidence.  Hence  , 
the  wiser  plan  would  be  to  open  the  bladder,  as  in  the  lateral 
operation  for  stone,  as  was  first  practised  by  Dr.  W.  J.  Walker,^ 
of  Boston,  in  a  man  thirty-three  years  of  age.  Although  there 
was  great  depression  at  tlie  time  of  the  operation,  twenty-four 
hours  after  the  injury,  and  there  was  fracture  of  the  pelvic  bones, 
immediate  improvement  followed,  and  the  man  resumed  his 
occupation  on  the  fifty-fifth  day.  The  rent  was  supposed  to 
have  existed  in  the  anterior  wall  of  the  organ.  Six  ounces  of 
urine  were  drawn  off',  with  marked  relief,  soon  after  the  receipt 
of  the  wound. 

'  Dublin  Journal  of  Medical  Science,  vol.  ix.,  188G,  p.  349. 
2  Medical  Communications  of  the  Massachusetts  Medical  Society,  vol.  vii., 
case  vi.,  1845. 


324  RUPTURE    OF    THE    BLADDER. 

The  practice  pursued  by  Dr.  AValker,  in  the  above  case,  deserves 
to  be  imitated  not  only  when  the  rupture  occupies  the  anterior 
wall  of  the  bladder,  but  when  it  involves  the  posterior  wall.  In 
an  instance  of  this  description,  complicated  by  general  peritonitis, 
from  extravasation  of  urine  into  the  pelvic  cavity,  occurring  in 
a  man,  twenty-six  years  of  age.  Dr.  Erskine  Mason,'  of  Xew 
York,  made  the  lateral  section,  sixty-two  hours  after  tbe  accident, 
and  evacuated  a  large  quantity  of  bloody  urine.  Under  appro- 
priate measures,  the  peritonitis  subsided,  and  the  man  was  dis- 
charged on  the  thirty-seventh  day.  This  treatment  derives 
support  from  what  occurs  in  gunshot  wounds,  in  which,  the 
urine  having  an  opportunity  of  running  off  by  the  abnormal 
opening  as  fast  as  it  reaches  the  organ,  sevei'e  and  fatal  infiltra- 
tion is  rare.  It  need  hardly  be  added  that  the  sooner  the  opera- 
tion is  performed,  under  such  circumstances,  the  more  likely  will 
it  be  to  eventuate  successfully. 

In  the  first  edition  of  this  work,  published  in  1851, 1  suggested 
the  propriety  of  making  an  incision  through  the  linea  alba,  and 
sponging  out  the  extra vasated  fluid,  but  I  have  never  had  an 
opportunity  of  putting  it  in  practice.  In  1862,  however.  Dr. 
Walter,  of  Pittsburgh,^  in  the  case  of  a  man,  twenty-two  years 
of  age,  removed  successfully  in  this  way  a  pint  of  extravasated 
urine  and  blood,  which  proceeded  from  a  rent  two  inches  long 
in  the  base  of  the  bladder.  The  after-treatment  consisted  in  the  -^ 
liberal  exhibition  of  opium,  light  diet,  and  the  permanent  reten- 
tion of  a  catheter.  In  addition  to  this  precaution,  Mr.  Holmes' 
has  recently  advised  uniting  the  wound  with  silver  or  carbolized 
gut  ligatures. 

As  soon  as  reaction  has  been  brought  about  by  the  usual 
remedies,  the  patient  must  be  carefully  w^atched  to  guard  against 
the  occurrence  of  general  peritonitis.  At  the  approach  of  the^ 
first  symptoms,  if  the  condition  of  the  case  admits  of  it,  blood' 
should  be  freely  taken  from  the  arm,  or  the  belly  should  be 
covered  with  leeches,  followed  by  hot  fomentations.  The  appli- 
cation of  a  large  blister  might  be  beneficial  in  moderating  and 
circumscribing  the  resulting  inflammation.     Iced  milk  may  be 

'  New  York  Medical  Journal,  vol.  xvi.,  1872,  p.  113. 

2  Med.  and  Surg.  Reporter,  Feb.  1862. 

3  A  Treatise  on  Surgery,  Amer.  ed.,  1876,  p.  246. 


RUPTUEE    OF    THE    BLADDEE.  325 

allowed  in  small  quantities,  to  allay  thirst  and  sustain  strength, 
for  the  first  two  or  three  days ;  and  the  system  should  be  kept 
fully  under  the  influence  of  opium,  which  forms  the  sheet-anchor 
of  the  treatment.  If  the  patient  survives  the  first  efi:ects  of  peri- 
tonitis, abscesses  may  form  and  require  opening,  precisely  as  in 
extravasation  of  urine  from  rupture  of  the  urethra.  Under  these 
circumstances,  the  treatment  must  be  supporting. 


CHAPTER   XIY. 

FISTULE  OF  THE  BLADDER. 

The  lower  wall  of  the  female  bladder  and  urethra  is  liable, 
either  from  injury  or  disease,  to  various  kinds  of  tistules,  deriving 
their  names  from  the  organs  with  which  thev  communicate,  as 
vesico-vaginal,  urethro-vaginal,  urethro-vesico-vaginal,  vesico- 
uterine, vesico-utero-vaginal,  urethro-vesico-utero- vaginal,  and 
vesico-vagino-rectal.  In  the  following  pages  I  shall  confine 
myself  principally  to  the  consideration  of  vesico-vaginal  fistule, 
pointing  out  any  modifications  in  the  treatment  that  may  be 
required  by  ditferences  in  the  situation  or  size  of  the  opening ; 
and  to  vesico-rectal  fistule,  as  it  is  met  with  in  tlie  male. 

Sect.  I.— YESICO-VAGIXAL  FISTULE. 

Vesico-vaginal  fistule  is  an  opening  between  the  bladder  and 
vagina,  attended  with  a  discharge  of  urine  through  the  latter 
passage.  It  is  most  frequent  after  the  twenty-fifth  year,  particu- 
larly in  primiparfe  who  are  advanced  in  life,  and  it  is  occasionally, 
although  rarely,  congenital.  A  case  is  related  in  the  fifty-sixth 
volume  of  the  Dictionnaire  des  Sciences  Medicales,  in  which, 
while  the  labia,  nymphte,  and  clitoris  were  all  well  developed, 
there  was  an  absence  of  the  urethra  and  neck  of  the  bladder,  the 
urine  passing  oft'  constantly  by  the  vagina  through  an  opening 
in  the  vesico-vaginal  septum  large  enough  to  admit  the  finger. 
Dr.  Schatz*  has  recorded  a  remarkable  deformity  of  the  genito- 
urinary system  of  an  infant,  in  which  there  was  a  double  uterus, 
a  double  vagina,  a  double  bladder,  and  a  double  vesico-vaginal 
fistule. 

Although  the  communication  may  be  produced  by  the  mal- 
adroit use  of  instruments,  by  penetrating  wounds  of  the  vagina 
and  bladder,  by  ulceration,  whether  simple,  venereal,  or  malig- 
nant, by  the  formation  of  an  abscess,  or  by  the  pressure  of  a 

'  Arch.  f.  Gyniik.,  iii.  2,  1872. 


VESICO-VAGINAL    FISTULE.  327 

urinary  calculus,  a  pessaiy,  or  other  foreign  substance,  by  far 
the  most  common  cause  of  the  accident  is  sloughing  consequent 
upon  the  pressure  exerted  upon  the  septum  by  the  presenting 
portion  of  the  child  in  protracted  labor, 

A  great  diversity  exists  in  regard  to  the  seat,  size,  and  shape 
of  the  abnormal  aperture ;  circumstances  of  great  importance 
with  reference  both  to  the  diagnosis  and  treatment  of  this  afiec- 
tion.  The  most  common  sites  are  at  the  trigone  and  bas- 
fond  of  the  organ;  but  in  many  cases  it  is  just  below  the  uterus, 
and  sometimes  in  the  urethro-vaginal  septum.  The  size  of  the 
opening  may  not  exceed  the  diameter  of  a  small  shot,  or  it  may 
be  so  great  as  to  admit  a  pullet's  egg,  a  small  orange,  or  even  a 
larger  object.  In  its  shape  it  is  generally  somewhat  oval  or 
circular,  but  occasionally  it  presents  itself  in  the  form  of  a 
transverse,  oblique,  or  longitudinal  rent,  slit,  or  fissure.  Its 
edges  are  usually  well  defined,  rough,  callous,  and  white,  with 
a  slight  eversion  of  the  vesical  mucous  membrane.  The  indu- 
ration often  extends  a  considerable  distance  beyond  the  fissure, 
especially  when  tliis  has  been  caused  by  sloughing,  and  hence  it 
is  occasionally  no  easy  matter  to  pare  the  edges  of  such  an  open- 
ing with  a  view  to  the  introduction  of  the  suture.  The  vagina 
in  the  neighborhood  of  the  aperture  may  be  perfectly  sound,  or 
it  may  be  variousl}^  altered  by  disease,  according  to  the  nature 
of  the  exciting  cause  of  the  fistule,  the  violence  of  the  resulting 
inflammation,  and  the  acrid  character  of  the  discharges.  It  is 
extremely. rare  that  there  is  more  than  one  opening. 

A  singular  eversion  of  the  bladder  occasionally  takes  place  in 
vesico-vaginal  fistule,  the  lining  membrane  passing  through  the 
opening  so  as  to  form  a  tumor  in  the  vagina.  The  protrusion, 
which  is  seldom  considerable,  is  generally  of  so  trifling  a  nature 
as  not  to  re(|uire  any  particular  treatment.  When  the  artificial 
aperture  is  unusually  large,  the  whole  bladder  may  project 
through  it,  and  eventually  even  protrude  at  the  vulva,  as  in  a 
remarkable  case  which  w^as  communicated  to  me  in  1852,  by  the 
late  Professor  Howard,  of  Columlms,  Ohio.  It  occurred  in  a 
woman  who,  during  her  first  labor,  five  years  previously,  had 
received  an  extensive  laceration  of  the  perineum  and  of  the 
vesico-vaginal  septum.  Four  years  afterwards,  she  gave  birth 
to  another  child,  and  some  months  after  that  event  she  observed, 
for  the  first  time,  a  tumor  in  the  vagina.     Upon  examining  the 


328  FISTULE    OF    THE    BLADDER. 

parts,  Dr.  Howard  found  that  the  fundus  of  the  bladder  was 
completely  everted,  and  that  it  hung  through  the  vulva,  in  the 
form  of  a  red  mass,  of  the  volume  of  a  large  orange,  and  of  a 
o;lohular  shape,  with  a  rounded  and  rather  narrow  pedicle,  en- 
circled by  the  edges  of  the  vesico-vaginal  fistule.  The  orifices 
of  the  ureters  were  seen  at  its  posterior  extremity,  within  the 
vagina.  The  surface  of  the  tumor  was  rough,  ulcerated,  and  of 
a  deep  reddish  color.  The  woman  was  in  a  most  wretched  con- 
dition ;  her  general  health  was  much  impaired,  and  she  was 
unable  to  stand  erect  or  to  approximate  her  thighs.  The  urine 
dribbled  constanth'  from  the  vagina,  thus  adding  greatly  to  her 
suffering. 

A  female  affected  with  vesico-vaginal  fistule  must  necessarily 
be  an  object  of  the  deepest  commiseration.  Incapable  of  con- 
trolling the  contents  of  her  bladder,  the  urine  constantly  escapes 
at  the  vagina,  thus  soiling  her  clothes,  and  giving  rise  to  the 
most  noisome  odors,  which  no  amount  of  cleanliness  can  entirely 
prevent.  In  consequence  of  this  condition,  she  is  rendered  unfit 
for  social  enjoyment,  and  is  obliged  to  spend  her  life  in  solitude 
and  retirement.  The  urine,  incessantly  dribbling  away,  chafes 
and  frets  the  parts  with  which  it  comes  in  contact,  and  thus 
renders  them  unfit  for  the  exercise  of  their  appropriate  functions. 
The  escape  of  urine  is  constant  when  the  opening  is  situated  at 
the  bas-fond  of  the  bladder,  and  is  always  worse  in  the  erect 
than  in  the  recumbent  posture. 

Atroph}'  of  the  bladder,  amounting  almost  to  complete  absence 
of  the  viscus,  may  result  from  unrelieved  vesico-vaginal  fistule, 
as  in  the  case  of  a  woman,  forty  years  of  age,  dead  of  phthisis, 
examined  by  Professor  Uytterhceven.^  Up  to  the  age  of  twelve, 
when  she  began  to  menstruate,  she  had  complete  control  over 
the  bladder,  when  she  began  to  suffer  from  incontinence,  which 
continued  up  to  her  death,  due  to  a  urethro-vaginal  fistule,  the 
probable  result  of  softened  tubercle.  The  urine  being  discharged 
as  rapidly  as  it  was  secreted,  the  bladder  ceased  to  act  as  a 
reservoir  for  that  fluid,  and  it  became  reduced  to  the  size  of  an 
ordinary  pea.  It  was  lined  by  mucous  membrane,  and  presented 
on  its  inner  surface  a  minute  orifice  which  marked  the  site  of 
the  right  ureter,  the  lower  third  of  which  was  converted  into  a 

'  Presse  >Ied.  Beige,  Xo.  29,  1860. 


VESICO-VAGIXAL    FISTULE.  329 

ligamentous  cord,  and  the  parenchyma  of  the  corresponding 
kidney  was  substituted  by  a  caseous  mass  contained  in  a  thick- 
ened envelop.  The  left  ureter,  which  was  hypertrophied  and 
dilated,  opened  on  a  level  with  the  fistule. 

The  diagnosis  of  this  affection  is,  in  general,  sufficiently  easy. 
In  most  cases,  indeed,  the  escape  of  the  urine  by  the  vagina,  in- 
stead of  through  the  natural  channel,  serves  at  once  to  point  out 
its  true  character,  whatever  may  have  been  the  nature  of  the 
exciting  cause.  Its  situation,  shape,  and  extent,  however,  can 
be  determined  only  by  a  tliorough  vaginal  examination  by  means 
of  Sims's  speculum.  During  the  exploration  the  woman  may  lie 
on  her  side,  or,  what  is  better,  rest  on  her  kness  and  elbows,  with 
the  head  as  dependent  as  possible  and  the  nates  considerably 
elevated.  The  instrument,  well  oiled,  is  then  introduced  in  the 
usual  manner,  a  catheter  being  at  the  same  time  inserted  into 
the  urethra.  In  this  way  every  portion  of  the  vagina  may  be 
most  satisfactorily  inspected,  and  any  opening,  however  small, 
easily  detected.  In  some  instances,  the  speculum  is  advantage- 
ously replaced  by  the  finger,  which  is  carried  about  in  different 
directions,  along  the  anterior  wall  of  the  tube,  until  its  extremity 
comes  in  contact  with  the  naked  end  of  the  catheter.  When  the 
aperture  is  very  small,  a  long  slender  probe  should  be  used  instead 
of  the  latter  instrument. 

The  prognosis  of  vesico-vaginal  fistule  is,  in  general,  anything 
but  flattering.  If  a  spontaneous  cure  do  occasionally  occur,  the 
circumstance  is  so  infrequent  that  it  must  always  be  regarded 
merely  as  an  exception  to  one  of  the  most  uniform  laws  of  the 
animal  economy.  The  probability  of  such  an  event  will  be  con- 
siderably greater,  other  things  being  equal,  when  the  accident 
has  been  produced  by  a  simple  wound  than  when  it  has  been 
caused  by  a  severe  contusion,  followed  bj"  a  slough,  when  the 
opening  is  small  than  when  it  is  large,  and  when  the  lesion  is 
simple  than  when  it  is  complicated  with  other  affections.  The 
presence  of  malignant  disease,  of  course,  forbids  the  hope  even 
of  temporary  relief  by  any  operation  whatever.  Nothing  but 
the  most  determined  perseverance  and  the  application  of  the 
greatest  skill  will  be  likely,  even  in  the  more  simple  forms  of 
the  lesion,  to  eventuate  in  a  complete  and  permanent  cure. 

The  treatment  of  vesico-vaginal  fistule  is  palliative  and  radi- 
cal ;  the  former  consisting  in  the  employment  of  such  means  as 


330  FISTULE    OF    THE    BLADDER. 

are  calculated  to  promote  temporary  comfort,  and  the  latter  of 
such  measures  as  are  designed  to  eftect  the  permanent  closure  of 
the  abnormal  aperture. 

Frequent  ablutions  and  injections  with  cold  Avater,  either 
simple  or  medicated,  and  the  occasional  use  of  chlorinate  of 
soda,  will  prevent  excoriations  and  fetor,  and  a  proper  regula- 
tion of  the  diet,  with  a  soluble  condition  of  the  bowels,  will 
2;o  far  in  preserving  the  general  health,  which,  under  opposite 
circumstances,  sometimes  suffers  most  severely,  the  patient 
becoming  nervous,  dyspeptic,  and  even  hysterical.  To  guard 
against  the  incessant  escape  of  urine,  and  enable  the  poor 
patient  to  exercise  occasionally  in  the  open  air,  the  vagina 
should  be  kept  constantly  tilled  with  a  hollow  plug,  or  caout- 
chouc bottle,  enveloped  in  oiled  silk,  and  furnished  with  a  tube 
and  stopcock,  in  order  that  it  may  be  inflated  or  emptied  at 
pleasure. 

The  radical  cure  of  vesico-vaginal  fistule  may  be  effected  by 
cauterization,  incision,  and  suture.  Cauterization  of  the  edges 
of  the  fistule  is  applicable,  as  a  general  rule,  only  in  cases  of 
recent  standing,  and  where  the  opening  is  very  small.  Under 
such  circumstances,  complete  and  permanent  cures  have  occa- 
sionally been  effected,  but  the  remedy  requires  frequent  repeti- 
tion and  the  utmost  perseverance  to  insure  success.  It  may  be 
effected  by  the  actual  or  galvanic  cautery,  or  by  the  acid  nitrate 
of  mercury,  applied,  at  first,  every  fourth  day,  and  afterwards 
once  a  week  or  fortnight,  the  object  being  merely  to  excite  the 
granulating  process. 

Incision  has  occasionally  been  employed  successfully.  The 
operation  is,  of  course,  applicable  only  when  the  cleft  occupies 
the  neck  of  the  bladder,  and  is  unattended  with  anj'  material 
loss  of  substance.  Under  such  circumstances,  the  urethra  should 
be  divided  through  its  entire  extent  from  before  backwards,  and 
the  parts  then  treated  as  in  ordinary  fistule. 

The  method  by  suture,  although  subject  to  frequent  fjulure,  is 
far  preferable  to  any  other,  and  should,  therefore,  be  studied 
with  great  care  and  attention.  Its  origin  is  generally,  and  per- 
haps correctly  enough,  ascribed  to  the  celebrated  Dutch  surgeon, 
Roonhuyze,^  who  flourished  in  the  seventeenth  century,  and  ac- 

'  Heebkoustige  Aumeikingcn,  Amsterdam,  1663. 


VESICO-VAGINAL    FISTULE.  331 

quired  mucli  distinction  in  the  treatment  of  the  diseases  of  the 
genito-urinary  organs.  It  does  not  comport  with  the  scope  of 
this  work  to  enter  into  a  history  of  this  plan  of  treatment,  or  to 
speak  of  the  various  modifications  which  it  has  undergone  in  tlie 
hands  of  different  practitioners ;  suffice  it  to  say  that  the  opera- 
tion, as  practised  at  the  present  day,  was  first  performed,  in  May, 
1833,  by  Mr.  Gossett,^  Surgeon  to  l^ewgate,  London,  for  a  fistula 
the  result  of  vaginal  lithotomy.  Three  gilt  wires  were  inserted 
and  twisted,  and  an  elastic  catheter  retained  in  the  bladder. 
The  case,  however,  failed  to  attract  attention;  and  it  was  reserved 
to  Dr.  Sims,  in  1852,  to  place  the  operation  on  a  secure  and 
scientific  foundation.  Dr.  Bozeman  is  also  entitled  to  great 
credit  in  this  direction  ;  but  the  operation  of  Dr.  Sims,  based  as 
it  is  upon  numerous  original  trials,  and  the  invention  of  highly 
ingenious  instruments,  is  deserving  of  the  greatest  praise,  and 
justly  entitles  that  distinguished  surgeon  to  the  thanks  of  the 
profession,  and  the  gratitude  of  the  class  of  sufterers  for  whose 
benefit  it  was  devised. 

Before  any  operation  of  this  kind  is  undertaken,  I  deem  it  to 
be  a  matter  of  paramount  importance  to  subject  the  patient  to  a 
certain  amount  of  preliminary  treatment.  Without  this  precau- 
tion, failure,  not  success,  will  be  likely  to  attend  our  efibrts. 
The  treatment  need  not  be  protracted,  but  it  should  be  thorough, 
both  as  it  respects  the  parts  and  the  system  at  large.  The  most 
absolute  recumbency  and  cleanliness  should  be  observed ;  the 
vagina  should  be  frequently  syringed  with  cold  water  ;  cold 
cloths  should  be  kept  constantly  upon  the  vulva  ;  the  bowels  and 
secretions  should  be  properly  regulated ;  the  diet  should  be  per- 
fectly plain  and  simple;  and  large  quantities  of  bland  drinks 
should  be  used  to  dilute  the  renal  secretion,  and  deprive  it  of  its 
acrimony.  If  the  woman  be  pletliorie,  blood  should  be  taken 
from  the  arm,  or  from  the  vulva,  perineum,  groins,  and  thighs, 
b}'  means  of  leeches. 

If  the  jDarts  be  unduly  inflamed,  they  should  be  touched,  every 
other  day,  with  solid  nitrate  of  silver,  until  this  symptom  has 
measurably  disappeared.  Any  contraction  that  may  exist  in  the 
vagina  must  be  divided  and  permitted  to  heal  over  a  plug.  The 
evening  before  the  operation  a  brisk  purgative  is  administered 

'  Loudon  Lancet,  Nov.  29,  1834. 


332 


FISTULE    OF    THE    BLADDER. 


to  clear  out  the  alimentary  canal,  and,  on  the  following  morning, 
a  full  opiate  is  exhibited  to  keep  the  bowels  quiet. 

In  performing  the  operation,  the  first  thing  to  be  attended  to 
is  to  obtain  a  full  view  of,  and  ready  access  to,  the  affected  parts. 
For  this  purpose,  the  anpesthetized  patient  is  placed  on  her  knees 
and  elbows  at  the  edge  of  the  bed  upon  a  firm  hair  mattress, 
protected  by  a  piece  of  oil-cloth  and  a  folded  sheet,  the  nates 
being  elevated  by  pillows  laid  under  the  abdomen,  and  the  head 
and  shoulders  supported  b}-  a  single  pillow.  The  thighs,  sepa- 
rated about  eight  inches,  should  form  a  right  angle  with  the  bed. 
The  flexed  legs  are  now  confided  to  assistants,  who,  at  the  same 
time,  pull  the  nates  upwards  and  outwards,  the  tips  of  the  fingers 
resting  on  the  labia.  The  speculum  of  Sims,  fig.  90,  or  the  self- 
retaining  instrument  of  Emmet,  fig,  91,  being  next  introduced, 


Fi.sr.  90. 


Fie:.  91. 


Sims's  Spaculiira. 


Emmett's  Speculum. 


the  vagina  is  widely  dilated,  and  the  fistule  brought  completely 
into  view.  In  addition  to  the  precautions  already  described,  it 
is  necessary  to  have  a  strong  northern  light ;  but  when  this  is 
not  sufiieient,  a  small  mirror  may  be  used,  the  reflection  of  which 
will  generally  make  everything  distinct,  and  enable  the  surgeon 
to  proceed  without  any  embarrassment  from  this  cause. 

The  second  stage  of  the  procedure  consists  in  bevelling  the 
edges  of  the  fissure  at  the  expense  of  the  mucous  membrane  of 
the  vagina,  the  amount  of  substance  removed  depending  upon 
the  degree  of  induration,  but,  in  general,  averaging  from  one- 
third  to  half  an  inch,  so  as  to  form  an  ample  surface  for  approxi- 
mation.    If  the  opening  is  circular,  unusually  large,  or  longi- 


YESICO-VAGIXAL    FISTULE. 


533 


tuclinal,  the  edges  should  be  removed  in  such  a  way  as  to  admit 
of  being  brought  together  transversely,  otherwise  complete  union 
may  not  be  effected.  The  instruments  required  for  paring  the 
fistule,  represented  in  figs.  92,  93,  94,  95,  and  96,  are  a  delicate 


Fisr.  92. 


Fii?.  93. 


Fiir.  9i. 


Fiff.  95. 


Fii?.  9G. 


tenaculum  and  long,  slender,  toothed  forceps  for  holding  the 
edges,  and  a  straight  and  angular  knife,  made  for  the  right  and 
left  hands,  as  well  as  a  pair  of  scissors,  with  very  short  blades, 
slightly  curved  on  the  flat,  for  removing  the  mucous  membrane. 
The  lower  border  of  the  fistule  is  pared  first,  and  this  is  done 
most  easily  by  transfixion  with  the  straight  knife.  For  refresh- 
ing the  upper  border,  the  curved  knife  or  scissors  will  be  found 
more  convenient.  When  the  fistule  is  seated  high  up  in  the 
vagina,  the  harpoon,  or  pronged  guide,  of  Mr.  Bryant,^  which  is 


•  Guy's  Hospital  Reports,  ser.  3,  vol.  xi.  p.  2o9. 


334 


FISTULE    OF    THE    BLADDER. 


made  of  various  sizes  and  shapes,  will  answer  an  excellent  pur- 
pose, as  it  insures  accuracy  in  the  width,  length,  and  evenness 
of  the  incisions.  The  extent  of  the  surface  to  be  vivified  having 
been  mapped  out  by  a  scalpel,  the  prongs  of  the  guide,  suppos- 


Fis.  97. 


Fig.  98. 


Fig.  99. 


BryaLl"f  lui'trameDt  for  Paring  the 
EUgex  uf  ilie  Fistule. 


n 


Needle  Holder. 


TTook  for  mak- 
iDg  Counter-Pres- 
sure. 


ing  the  upper  border  to  be  the  one  operated  on,  as 
in  fig,  97,  from  Bryant,  are  inserted  at  the  edge  of 
the  mucous  membrane  of  the  bladder,  and  passed 
between  the  tissues  l)eneath  tlie  vaginal  mucous 
membrane,  and  brought  out  at  the  line  of  the  pre- 
liminary incision,  when  the  tissues  thus  included 
are  pressed  down  upon  the  base  of  the  prongs  with 
a  blunt  hook,  and  removed  by  carrying  the  knife  in  close  contact 
with  its  posterior  surface.  In  denuding  the  edges  of  an  unusu- 
ally large  fistule,  the  operator  is  sometimes  embarrassed  by  the 
protrusion  of  the  vesical  mucous  membrane ;  but  the  obstacle 
may  usually  be  overcome  by  returning  the  folds,  and  inserting 
a  soft  sponge  into  the  opening  until  all  the  stitches  are  inserted. 
In  excising  the  tissues,  there  must  necessarily  be  some  bleed- 
ing, though  this  is  seldom  sufficient  to  cause  any  annoyance  or 
serious  delay.     The  best  contrivance  for  clearing  away  the  blood 


VESICO-VAGINAL    FISTULE. 


835 


is  a  sponge  mop,  tlie  gentle  pressure  of  which  upon  the  lips  of 
the  wound,  aided,  if  necessary,  by  the  application  of  bits  of  ice. 


Fiir.  100. 


Fisr.  101. 


Fiff.  102. 


lufiofinctioD  of  Sutares. 


is  quite  sufficient  to  arrest  anj- hemor- 
rhage. 

The  third  step  of  the  operation 
consists  in  introducing  the  sutures, 
which  should  be  of  silver.  The  in- 
struments required  for  this  purpose 
are  several  armed  needles,  of  the  pat- 
tern of  those  of  Mr.  Lister  for  carry- 
ing metallic  threads,  at  least  an  inch 
and  a  half  long ;  the  needle-holder, 
represented  in  fig.  98 ;  the  long  for- 
ceps, and  a  blunt  hook,  fig.  99.  The 
parts  having  been  steadied  by  the 
toothed  forceps,  the  first  snture  is 
passed  through  the  centre  of  the 
opening,  by  entering  the  needle  at 
least  one-third  of  an  inch  below  the 
lower  edge  of  the  pared  fistule,  and 
bringing  it  out  at  the  mucous  mem- 
brane of  the  bladder,  without  includ- 
ing it.     It  is  then  carried  across  the 

opening  and  entered  at  the  lower  edge  of  the  upper  border  and 
brought  out  at  the  same  distance  through  the  mucous  membrane. 


Suture  Carrier.       Suture  Adjuster. 


336 


FISTULE    OF    THE    BLADDER. 


its  passaire  from  Avithin  outwards  being  facilitated  witli  the 
blunt  hook,  as  in  fig.  100.  The  remaining  sutures  are  inserted 
in  the  same  manner,  the  number  necessarily  varying  according 
to  the  extent  of  the  fistule.  The  interval  between  each  two, 
however,  should  be  three-sixteenths  of  an  inch. 

An  excellent  substitute  for  the  needle  and  holder  for  intro- 
ducing the  stitches,  is  Dr.  G.  S.  Bryant's  modification  of  Starten's 
canulated  needle,  shown  in  fig.  101. 

The  arrangement  of  the  wires,  and  the  closure  of  the  fistule 
constitute  the  last  stage  of  the  operation.  '  To  efl:ect  these  objects, 
the  ends  of  the  central  wire  are  passed  through  the  hole  of  tlie 
adjuster,  fig.  102,  and  firmly  held  between  the  thumb  and  fore- 
finger, and  drawn  upon  while  the  instrument  is  slipped  down 
and  well  pressed  against  the  parts.  The  remaining  sutures  are 
dealt  with  in  the  same  way,  so  as  to  insure  accurate  contact  of 
the  raw  surfaces,  as  represented  in  fig.  103.  The  wires  are  then 
twisted  together,  or  the}-  are  fixed  by  firmly  compressing  per- 
forated shot  on  them  at  the  line  of  adjustment,  and  clipping  ofi" 
the  ends  close  to  each. 


Fiff.  103. 


Fi-    104. 


r  f  f 


Adjustment  of  the  Sutures. 


Bozemau's  Button  Suture. 


With  a  view  to  give  steadiness  and  support  to,  and  prevent 
inversion  or  e version  of  the  edges,  Dr.  Bozeman  makes  use  of  a 
leaden  button,  the  concave  surface  of  which  rests  in  contact  with 
the  vesico- vaginal  septum,  where  it  is  secured  by  shot.  Fig. 
10-4  represents  the  apparatus  previous  to  its  final  adjustment. 

At  the  conclusion  of  the  operation,  the  vagina  and  surround- 
ing parts  having  been  cleansed  of  blood,  the  patient  is  put  to 
bed,  and  a  Sims's  catheter,  fig.  105,  inserted  into  the  bladder,  a 
gum  tube  having  previously  been  attached  to  its  proximal  ex- 
tremity, in  order  to  conduct  the  urine  into  a  bottle  [>laced 
between  the  thig-lis. 


V  E  S I C  0  -  V  A  G I X  A  L    F I S  T  U  L  E  . 


337 


Certain  modifications  of  this  procedure  are  fre-        Fig.  105. 
quently  demanded  on  account   of  tlie  situation  or 
extent  of  the  abnormal  opening. 

When  the  fistule  is  seated  in  the  urethro-vaginal 
septum,  the  operation  is  very  easy  of  execution  ;  but 
as  the  parts  are  thin,  and  liable  to  give  way  from 
the  pressure  of  the  catheter,  a  long,  very  concave 
button,  notched  at  its  extremity,  where  it  extends 
forwards  in  front  of  the  urinary  meatus,  will  afford, 
the  desired  support.  The  catheter,  which  should 
be  of  gum-elastic,  is  introduced  before  the  sutures 
are  adjusted. 

In  vesico-uterine  fistule,  in  which  the  communi- 
cation exists  between  the  bladder  and  neck  of  the 
uterus,  and  the  urine  escapes  at  the  mouth  of  the 
latter  organ,  the  anterior  lip  must  be  slit  up  until,  sims'.^ catheter. 
the  aperture  is  brought  into  view,  when  its  edges 
are  denuded,  and  the  entire  wound  closed  in  the  usual  manner, 
as  represented  in  fig.  106. 

It  sometimes  happens  that  the  vesico-vaginal  septum  is  des- 
troyed almost  from  one  extremity  to  the  other,  leaving  an 
opening  which  it  is  impossible  to  close 
by  the  ordinary  operation.  In  such  an 
event,  which  is  well  represented  in  fig.  107, 
from  Sims,  the  vagina  will  have  to  be  ob- 
literated by  the  free  paring  of  the  labia  ;  or, 
what  is  still  better,  its  upper  portion  and 
the  bladder  converted  into  a  common  cavity. 
For  this  purpose,  the  vesico-vaginal  septum, 
a,  and  the  posterior  wall  of  the  vagina,  c, 
are  thoroughly  denuded,  and  approximated 
b}'  silver  sutures.  The  menses  escape  by  the 
urethra,  and,  although  the  patient  is  ren- 
dered incapable  of  impregnation,  this  pro- 
cedure is  the  only  means  of  making  her 
comfortable.  In  some  cases,  however,  in 
which  the  destruction  of  the  parts  is  less 
extensive,  the  size  of  the  opening  may  be  materially  diminished 
by  dragging  down  the  uterus  with  forceps,  daily,  for  several 

weeks,  as  suggested  by  Bozeman,  and  uniting  its  anterior  lip 
90      " " 


The  Cervix  slit  up  to  Ex- 
pose the  Fistule  above,  ■with 
the  Sutures  iu  Position. 


338 


FISTULE    OF    THE    BLAPDEB. 


witli  tlie  vesico-vaginal  septum.     Should  the  posterior  lip  have 
to  be  used  for  this  purpose,  as  occasionally  happens,  the  neck  of 


Fi£'.  107. 


Case  of  Vesico-Vaginal  Fistnle  requiring  Obliteration  of  the  Vagina 


the  organ  will  have  to  remain  imprisoned  in  the  bladder.  Simi- 
lar procedures  arc  required  in  cases  of  vesico-utero-vaginal 
tistules. 

Much  of  the  success  of  this  operation,  and,  indeed,  every 
other  of  a  similar  kind,  will  depend  upon  the  after-treatment. 
As  soon  as  the  patient  is  put  to  bed,  she  should  take  a  large 
anodyne,  for  the  twofold  purpose  of  allaying  pain  and  inducing 
quiescence  of  the  bowels,  which  should  not  be  disturbed  under 
ten,  twelve,  or  fifteen  days.  The  diet  should  consist  exclusively 
of  animal  brotlis,  potato,  bread,  crackers,  custard,  rice,  milk, 
and  tea,  with  water  as  the  common  drink.  Opium  is  given 
twice  a  day  in  as  large  doses  as  can  be  borne  ;  and  the  patient 
is  never  permitted,  even  for  a  moment,  or  for  any  purpose  what- 
ever, to  assume  the  erect  posture,  though  she  may  if  she  prefer 
it  lie  on  either  side.  The  catheter  is  to  be  removed  as  often  as 
may  be  necessary  to  keep  it  clear  of  mucus  and  calculous  matter; 
once  a  day,  once  every  other  day,  or  once  every  third  day,  ac- 
cording to  the  circumstances  of  each  individual  case.  The  vulva 
and  orifice  of  the  vagina  should  be  syringed  at  least  twice  in 
the  twenty-four  hours  with  tepid  water,  a  large  bed-pan  being 
placed  under  the  nates  during  each  operation  to  receive  the  fluid 
as  it  runs  off. 

Undue  inflammation  is  treated  on  general  principles.  Both 
part  and  system  are  occasionally  endangered  by  erysipelas.     In 


VESICO-RECTAL    FISTULE.  339 

a  patient  under  my  charge  several  3'ears  ago,  although  more  than 
usual  care  had  been  bestowed  upon  the  preliminary  treatment, 
a  most  violent  attack  of  this  disease  took  place  within  a  few 
days  after  the  operation,  commencing  on  the  right  buttock,  and 
gradually  spreading  over  the  upper  part  of  the  thigh,  perineum, 
and  vulva,  from  which  it  speedily  extended  into  the  vagina, 
causing  large  deposits  of  lymph,  with  a  strong  disposition  to 
cohesion.  The  constitution  suffered  very  much,  and  at  one  time 
I  was  not  without  serious  apprehension  in  regard  to  the  ultimate 
issue  of  the  case.  ^Notwithstanding  all  this,  however,  the  woman 
made  a  good  recovery,  although  several  months  elapsed  before 
she  fully  regained  her  strength. 

Peritonitis  has  occasionally  occurred  after  this  operation,  and 
it  is  well  enough  always  to  have  an  eye  to  the  possibility  of  sucli 
an  event ;  so  that,  should  it  show  itself,  it  may  be  promptly 
combated.  It  will  rarely  appear  before  the  third  day,  or  after 
the  sixth  or  eighth. 

The  sutures  should  not,  as  a  general  rule,  be  removed  before 
the  tenth  or  twelfth  day ;  if  taken  out  sooner,  the  adhesions 
may  give  way,  and  thus  necessitate  a  repetition  of  the  operation. 
TJie  patient  being  placed  in  the  position  already  described,  and 
the  speculum  introduced,  the  shot  are  successively  seized  with 
the  forceps  and  drawn  from  the  parts,  so  as  to  bring  the  wires 
into  view,  when  they  are  clipped  with  the  curved  scissors,  with- 
drawal being  assisted  by  supporting  the  loops  on  their  distal  side. 
The  patient,  instead  of  sitting  up  or  walking  about,  observes 
the  recumbent  posture  for  several  days  longer,  and  the  use  of 
the  catheter  is  continued  until  there  is  reason  to  believe  that  the 
new  cicatrice  has  acquired  sufficient  strength  to  resist  the  pres- 
sure of  the  distended  bladder  and  the  traction  of  the  surrounding- 
parts. 

Of  204  cases  of  this  operation,  recorded  by  Bozeman,  Brown, 
Simon,  and  Agnew,  18,  or  1  in  every  17,  proved  fatal. 

Sect.  IL— VESICO-RECTAL  FISTULE. 

Under  tliis  head  are  included  abnormal  openings  between  the 
bladder  and  rectum,  and  between  the  latter  tube  and  the  urethra. 
The  lesion  may  be  produced  by  numerous  causes,  of  which  the 
most    common   are   incised,  punctured,  and    gunshot    wOunds, 


340  FISTULE    OF    THE    BLADDER. 

ulceration,  abscess,  or  malignant  disease.  It  is  sometimes  a  result 
of  stricture  of  the  urethra ;  and  it  may  also  be  produced  by  the 
careless  use  of  a  metallic  catheter  or  bougie.  A  calculus,  perma- 
nently arrested  behind  the  prostate  gland,  may,  by  its  pressure, 
induce  ulceration,  and  make  its  way  from  the  bladder  into  the 
bowel,  and  so  occasion  the  affection  in  question. 

The  characteristic  sign  of  rectal  fistules  is  the  interchange  of 
the  contents  of  the  two  contiguous  reservoirs,  the  urine  passing 
into  the  boAvel  and  the  feces  into  the  bladder.  In  the  urethral 
variety,  the  urine  escapes  into  the  bowel  only  during  micturi- 
tion ;  while  in  the  vesical  form,  the  feces  are  discharged  by  the 
urethra  solely  during  the  same  act.  In  consequence  of  this 
occurrence,  the  parts  arc  apt  to  become  sore  and  irritable  from 
the  contact  of  substances  which  are  entirely  foreign,  and,  there- 
fore, injurious  to  them.  Moreover,  the  constant  introduction 
of  fecal  and  other  matter  into  the  bladder  is  liable  to  give  rise 
to  calculous  concretions  and  to  retention  of  urine.  Effects 
similar  to  these  may  result  from  a  tistulous  conmiunication 
between  the  bladder  and  the  ileum  or  the  bladder  and  the  colon ; 
doubt  may  also  arise,  under  such  circumstances,  as  to  the  actual 
location  of  the  opening.  When  this  is  the  case,  a  careful  exami- 
nation with  the  anal  speculum,  aided  with  a  slender  catheter, 
very  conical  at  the  point,  will  generally  enable  us  to  arrive  at  a 
correct  decision  respecting  the  real  nature  of  the  lesion. 

Vesico-rectal  and  urethro-rectal  fistules,  however  induced, 
will  often  disappear  of  their  own  accord.  In  all  cases,  the 
greatest  attention  should  be  paid  to  the  rectum,  which  should 
be  kept  constantly  free  from  fecal  matter,  the  ingress  of  which 
into  the  bladder  and  urethra  is  a  source  of  so  much  mischief 
and  suffering.  For  this  purpose,  especially  in  the  traumatic 
form  of  the  lesion,  the  bowels  should  be  maintained,  for  days 
together,  in  a  perfectly  quiescent  state  by  opium,  and  the  rectum 
should  be  washed  out  several  times  in  the  twenty-four  hours 
with  cold  water,  or,  if  the  discharges  be  fetid,  with  a  very  weak 
solution  of  chlorinate  of  soda.  The  recumbent  posture  should 
be  carefully  observed ;  the  diet  should  be  of  the  most  bland  and 
simple  character;  and  drinks  of  every  description  should  be  used 
as  sparingly  as  possible.  As  the  case  progresses,  the  closure  of 
the  fistule,  particularly  in  the  urethral  form  of  the  affection, 
may  often  be  greatly  promoted  by  the  frequent  withdrawal  of 


VESICO-RECTAL    FISTULE.  341 

the  urine  with  the  elastic  catheter,  thereby  preventing  the  eon- 
tact  of  that  fluid  with  the  abnormal  opening.  In  a  case  of  this 
description,  the  result  of  acute  prostatic  abscess.  Sir  Henry 
Thompson*  effected  a  cure  in  three  months  by  making  the 
patient  micturate  in  the  prone  position.  When  nature  fails  to 
accomplish  her  purpose,  a  cure  may  not  infrequently  follow  the 
use  of  nitrate  of  silver,  acid  nitrate  of  mercury,  or  the  galvanic 
or  actual  cautery,  applied  through  the  intervention  of  an  anal 
speculum.^  In  very  obstinate  cases,  especially  when  the  abnor- 
mal opening  is  situated  very  low  down,  the  edges  may  be  pared, 
and  united  by  suture,  as  in  vesico-vaginal  fistule ;  the  parts  being 
previously  dilated  by  the  bougie,  and  widely  opened  at  the  time 
of  the  operation  by  means  of  blunt  hooks.  "When  this  proceeding 
does  not  afford  the  requisite  room,  it  would  be  perfectly  proper, 
as  a  preliminary  step,  to  paralyze  the  sphincter  muscle  by  over- 
stretching its  fibres  with  the  thumbs. 

When  the  flstule  has  been  caused  by  the  operation  of  lithotomy, 
it  will  generally  close  spontaneously,  but  should  it  fail  so  to  do, 
I  would  hesitate  a  good  deal  before  I  would  divide  the  parts,  as 
has  been  recommended  by  different  surgeons.  The  worst  forms 
usualW  of  this  accident  are  those  w^hich  follow  the  recto-vesical 
section,  and  here  the  knife  may  occasionally  be  used  with  ad- 
vantage. 

A  very  remarkable  case  of  vesico-vagino-rectal  fistule  came 
under  ni}^  observation,  upw^ards  of  twenty  years  ago,  in  a  woman, 
twenty-seven  years  of  age,  in  consequence  of  protracted  labor, 
during  which  the  bladder  was  permitted  to  remain  distended' 
for  the  first  three  days.  As  a  result  of  a  violent  inflammation 
of  the  vagina,  that  passage,  as  well  as  the  urethra,  was  completely 
obliterated.  For  the  first  twelve  months  after  the  accident,  the 
urine  dribbled  ofi'  constantly  by  the  anus  ;  but,  after  that  period, 
she  was  able  to  retain  it  for  half  an  hour,  or  even  an  hour,  espe- 
cially when  she  was  in  the  erect  posture.  The  rectum,  which 
thus  served  the  purpose  of  an  accessory  receptacle  for  the  urine, 

'  Holmes's  System  of  Surger}"-,  vol.  iv.,  2cl  ed.,  p.  086. 

^  In  a  mau,  nearly  sixty  years  of  age,  the  editor  succeeded,  in  1868,  in  closing 
an  aperture  between  the  prostatic  urethra  and  the  rectum,  of  the  size  of  a  small 
quill,  by  the  application  of  a  cylinder  of  silver,  previously  dipped  in  strong 
nitric  acid,  and  drawing  off  the  urine  every  six  hours.  The  parts  were  touched 
only  three  times,  and  in  ten  days  the  cure  was  perfect. 


342  FISTULE    OF    THE    BLADDER. 

was  unusually  tender  and  irritable,  while  the  anus  constantly- 
exhibited  an  inflamed  and  excoriated  appearance.  The  orifice 
of  the  urethra  was  natural,  but  all  attempts  to  pass  an  instrument 
pro^'ed  abortive. 

Finding  it  impossible  to  restore  the  obliterated  vagina,  I  intro- 
duced a  laroi;e  curved  trocar  into  the  urethra,  for  the  purpose  of 
reestablishing  the  natural  channel  for  the  urine.  By  wearing  a 
self-retaining  catheter  for  several  weeks,  the  canal  was  completely 
restored  to  its  former  size,  the  urine  being  discharged  in  a  full 
stream,  and  not  oftener  than  once  every  four  liours.  She  had, 
in  fact,  the  most  thorough  control  over  the  bladder,  and  not  a 
drop  of  urine  escaped  by  the  anus. 


CHAPTER  XY. 

MALPOSITIONS  OF  THE  BLADDER. 

Sect.  I.— HERNIA  OF  THE  BLADDER. 

The  bladder,  like  the  other  abdominal  viscera,  is  liable  to 
protrude  from  the  pelvic  cavity,  constituting  what  is  denomi- 
nated a  cystocele.  The  protrusion  may  take  place  in  different 
regions,  the  principal  of  which  are  the  inguinal,  the  femoral,  and 
the  vaginal,  the  latter  of  whicli  is  its  most  common  seat ;  while 
it  is  rare  in  the  perineum  and  pudendum.  Verdier  saw  a  case 
where  the  bladder  with  the  urachus  and  umbilical  artery  was 
drawn  down  into  the  scrotum.  A  distended  bladder  has  occa- 
sionally descended  before  the  head  of  the  child  in  labor ;  and  an 
instance  is  recorded  b}^  Merriman,  where  a  tumor  thus  formed 
was  actually  opened  under  the  supposition  that  it  was  a  liydro- 
cephalus. 

A  hernia  of  this  description  is  sometimes  complicated  with  a 
bubonocele,  or  hernia  of  the  groin,  which  it  may  either  precede 
or  follow.  In  those  enormous  abdominal  ruptures,  in  which  a 
large  mass  of  the  intestinal  tube  is  protruded,  the  bladder  occa- 
sionally forms  a  constituent  part  of  the  tumor.  On  the  other 
hand,  the  bladder  sometimes  descends  first,  and  thus  paves  the 
way,  as  it  w^ere,  for  the  escape  of  the  bowel.  A  very  interesting 
fact  is  the  occasional  coexistence  of  stone  in  the  protruded  organ. 
Of  this  occurrence,  examples  are  mentioned  by  Rousset,  Ruysch, 
Tolet,  Paget,  Barlow,  and  others.  One  of  the  most  interesting, 
in  a  practical  point  of  view,  is  that  recorded  by  Sala,  in  which 
the  patient  had  all  the  symptoms  of  stone,  although  none  could 
be  felt  by  the  sound.  After  death,  the  foreign  body  was  found 
in  the  bladder,  which  was  contained  in  the  groin.  In  a  case 
reported  by  Petit,  the  calculi,  which  were  several  in  number, 
were  discharged  by  the  urethra.  Ilartmann  has  recorded  an  in- 
stance in  which  a  pudendal  C3-stocele  contained  a  stone  weighing 
three  ounces. 

Hernia  of  the  bladder  occurs  in  both  sexes,  and  at  different 


344  MALPOSITIONS    OF    THE    BLADDER. 

periods  of  life.  A  case  is  related  by  Pott  of  a  boy  of  tbirteen. 
Tlie  occurrence,  however,  is  most  common  in  elderly  male  sub- 
jects who  have  been  repeatedly  afflicted  with  retention  of  urine. 
Of  the  exciting  causes  nothing  special  is  known  ;  but  the  proba- 
bility is  that  they  do  not  differ  from  those  of  hernia  in  general. 
In  w^omen,  the  affection,  particularly  that  form  of  it  known  as 
vaginal  cystocele,  has  been  noticed  as  an  effect  of  dropsy  and 
pregnancy.  In  children,  it  has  sometimes  been  caused  by  the 
irritation  of  stone. 

The  cystic  hernia  is  destitute  of  a  proper  peritoneal  sac.  The 
only  exception  to  this  rule  is  where  the  rupture  is  of  long  stand- 
ing, or  the  tumor  is  of  great  bulk,  in  which  case  the  fundus  of 
the  bladder  may  drag  the  peritoneum  down  into  the  scrotum, 
so  as  to  form  a  hernial  sac,  into  which  a  portion  of  bowel  or 
omentum  may  afterwards  protrude.  The  swelling  is  always 
formed,  in  great  measure,  by  the  superior  portion  of  the  viscus, 
and  is  generally  of  small  size,  although  occasionally  it  has  been 
known  to  attain  the  magnitude  of  a  fist  or  of  a  goose's  egg. 
When  the  disease  is  complicated  with  bubonocele,  the  intestinal 
hernia  invariably  lies  in  front  of  the  cystic. 

In  a  case  observed  by  Mr.  "W.  J.  Clement,^  the  whole  bladder 
had  passed  out  through  the  left  abdominal  ring  down  into  tlie 
scrotum,  forming  an  enormous  tumor  which  occupied  both  the 
pubic  and  inguinal  regions,  and  was  nearly  fifteen  inches  in  length 
by  twenty-nine  in  circumference.  The  penis  was  completely 
buried  beneath  the  integuments,  and  the  urine  was  discharged 
through  an  opening  resembling  the  navel.  The  canal  through 
which  the  [trotrusion  had  taken  place  was  traversed  by  a  portion 
of  the  colon,  and  Avas  sufficiently  capacious  to  admit  the  entire 
hand.  The  sac,  formed  by  the  bladder,  looked  like  an  enormous 
hydrocele,  and  contained  two  quarts  of  fetid  urine,  which  escaped 
during  the  dissection  by  the  rupture  of  a  part  which  had  become 
red  and  inflamed  before  death. 

A  cystocele  is  a  soft,  elastic,  and  fluctuating  tumor,  which 
varies  in  its  size  according  to  the  amount  of  urine  contained  in 
the  protruded  part.  It  is  free  from  pain,  increases  from  above 
downwards,  attains  its  volume  in  a  slow  and  gradual  manner, 
and  api)ears  translucent  by  transmitted  light.     If  the  tumor  be 

'  Observations  in  Sur^-ery  and  Pathology,  p.  145.     London,  1832. 


HERNIA    OF    THE    BLADDER.  345 

compressed,  it  diminishes  in  size,  and  the  patient  experiences  an 
inclination  to  void  his  urine.  If  reducible,  it  returns  during 
recumbency,  but  reappears  soon  after  the  resumption  of  the  erect 
posture.  If,  on  the  contrary,  the  parts  are  adherent,  or  if  the 
muscular  coat  of  the  bladder  is  paralyzed,  the  patient  cannot 
expel  his  urine  unless  he  resorts  to  compression  and  elevation 
of  the  tumor. 

The  diagnosis  of  cystocele  is  a  matter  of  importance,  as  a  tumor 
of  this  kind  has  occasionally  been  cut  into  by  mistake.  The 
most  decisive  symptom  is  the  change  which  the  swelling  under- 
goes in  its  volume  during  micturition.  As  the  water  flows  oiT, 
the  tumor  decreases,  or  entirely  disappears,  to  recur  again,  how- 
ever, as  soon  as  tlie  urine  lias  reaccumulated  to  some  extent  in 
the  protruded  part.  A  cystocele  has  not  the  doughy,  inelastic 
feel  of  an  omental  hernia,  nor  the  soft  gaseous  feel  of  an  intestinal 
one,  nor  does  it  return  with  that  peculiar  gurgling  noise  which 
accompanies  the  ascent  of  the  latter.  AVhen  the  bladder  is 
contained  in  the  scrotum,  the  disease  might  be  mistaken  for  a 
hydrocele,  although  such  an  error  could  hardly  be  committed 
except  by  a  careless,  superficial  observer.  Pott^  cut  into  such  a 
tumor  under  the  supposition  that  he  was  dealing  with  a  diseased 
testicle ;  and  Verdier^  records  instances  in  which  the  bladder, 
seated  in  the  gi'oin,  was  mistaken  for  abscess  or  venereal  bubo. 

The  treatment  of  cystocele,  seated  in  the  groin  or  scrotum, 
does  not  differ  from  that  of  intestinal  hernia.  When  the  tumor 
is  reducible,  it  should  be  kept  up  by  means  of  an  appropriate 
truss ;  but  when  tlie  viseus  has  contracted  adhesions,  and  no 
longer  admits  of  reposition,  the  patient  must  be  contented  with 
a  suspensory  bag.  The  urine  which  accumulates  in  the  lower 
part  of  the  sac  must  be  discharged  by  raising  and  compressing 
the  tumor  during  micturition.  If  retention  should  take  place, 
and  relief  cannot  be  afforded  by  tlie  catheter,  the  part  should 
be  punctured.  If  calculi  collect,  and  become  a  source  of  great 
suffering,  they  may  be  extracted  by  incision  of  the  sac. 

In  vaginal  cystocele,  of  which  I  have  seen  several  examples, 
the  swelling  is  of  a  globular  shape,  free  from  pain,  and  of  a  soft 
ehrstic  feel,  imparting,  on  handling,  the  sensation  of  fluid  cou- 

'  Chirurg-ical  Works,  vol.  i.  p.  434.     Philadelpliia,  1819. 
2  Mem.  de  I'Acad.  Roy.  de  Cliir.,  t.  ii. 


846  MALPOSITIONS    OF    THE    BLADDER. 

tents.  Situated  at  the  anterior  portion  of  the  vagina,  the  tumor 
varies  in  volume  from  that  of  a  pigeon's  egg  up  to  that  of  a  fist, 
and  is  either  contained  within  the  tuhe,  or  protruded  beyond 
the  vulva.  In  the  more  aggravated  forms  of  the  complaint,  the 
entire  cylinder  of  the  tube  is  involved.  For  the  production  of 
this  affection  a  certain  degree  of  relaxation  of  the  walls  of  the 
vai^ina  is  necessary,  and  hence  it  is  most  common  in  females 
who  have  borne  many  children,  or  who  have  suffered  a  long 
time  under  leucorrhoea.  I  have  quite  recently  seen  a  case  of 
this  affection  in  a  girl  of  twenty,  in  other  respects  apparently 
quite  healthy,  except  that  she  always  sutiered  from  dysmenor- 
rhoea  at  lier  menstrual  periods  When  the  bladder  was  dis- 
tended the  tumor  completely  filled  the  external  orifice  of  the 
vagina,  forming  a  soft,  elastic,  white  cyst,  readily  indented  by 
the  finger,  free  from  pain,  and  imparting  a  distinct  impulse 
under  coughing.  "When  I  examined  it,  it  had  existed  for  up- 
wards of  a  year,  without  a  suspicion  on  the  part  of  the  patient 
of  its  true  nature.  When  the  tumor  protrudes  bej'ond  the 
vulva,  it  forms  a  translucent  sac,  not  unlike  a  serous  cyst,  or 
the  amniotic  bag.  The  diagnosis  is  determined,  first,  by  the 
facility  with  which  the  tumor  is  redm*ed ;  secondly,  by  the 
absence  of  any  o[)ening  in  its  walls;  thirdly,  b}'  the  want  of 
displacement  of  the  uterus  ;  and  fourthly,  b\^  the  fact  that  the 
volume  of  the  swelling  is  greatly  diminished  b}'  catheterism. 
An  instance  occurred  in  France,  in  which  a  protrusion  of  this 
kind  was  mistaken  by  a  medical  practitioner  for  a  prolapse  of 
the  uterus.  A  pessary  was  actually  forced  through  the  vagina 
into  the  l^ladder,  where  it  was  allowed  to  remain  five  months, 
causing  the  most  violent  suffering.  It  was  finally  extracted 
through  the  fistule,  but  not  without  the  greatest  difliculty  and 
pain.     Such  an  error  is  as  inexcusable  as  it  is  disgraceful. 

For  the  relief  of  ordinary  vaginal  cystocele,  the  principal 
remedies  are,  the  frequent  withdrawal  of  the  urine,  injections 
of  cold  astringent  lotions  into  the  vagina,  the  use  of  a  well- 
constructed  pessary,  and  rest  in  the  recumbent  posture.  The 
general  health  must  be  improved  by  laxatives,  light  but 
nourishing  diet,  and  the  use  of  chalybeate  tonics. 

In  tlie  more  rebellious  forms  of  the  affection,  attended  with 
inordinate  dilatation  of  the  vagina,  the  operation  of  elytrorraphy, 
the  objects  of  which  are  to  produce  diminution  of  the  capacity 


HERNIA    OF    THE    BLADDER. 


347 


Fie;.  108. 


of  the  vagina  and  aiFord  support  to  the  displaced  bhadder,  may 
be  performed,  the  process  of  Sims,  represented  in  fig.  108,  being 
the  one  usually  adopted.  The  anaesthetized  patient  being  placed 
on  her  left  side,  and  Sims's  largest  s[ieculum  introduced,  a  curved 
tenaculum  is  inserted  into  the 
neck  of  the  uterus,  so  as  to 
cause  a  prominent  fold  in  the 
anterior  wall  of  the  vagina, 
from  which  a  strip  of  mucous 
membrane,  from  one-third  to 
half  an  inch  in  width,  is  re- 
moved on  each  side,  with  the 
tenaculum  and  scissors,  com- 
mencing several  lines  above  the 
meatus  and  terminating  at  the 
side  of  the  neck  of  the  uterus, 
the  two  raw  surfaces  exhibiting 
somewhat  of  a  V-shaped  con- 
figuration. The  edges  of  the 
wound  are  tacked  together  by 
wire  sutures,  retained  until 
they  are  completely  united. 
The  subsequent  treatment  con- 
sists in  rest  in  bed ;  the  reten- 
tion of  the  catheter,  wdiich  is  removed  and  cleansed  twice  in 
the  twenty-four  hours ;  and  full  doses  of  opium  to  lock  up  the 
bowels. 

When  the  above  treatment  fails,  the  last  recourse,  and  it  is 
one  which  is  particularly  applicable  to  advanced  females,  for 
obvious  reasons,  is  closure  of  the  greater  portion  of  the  orifice 
of  the  vagina,  b}^  paring  the  labia  and  uniting  them  with  silver 
sutures.  The  operation,  which  has  frequently  been  performed 
with  a  good  result,  is  termed  episiorraphy. 

A  vaginal  cystocele  occasionally  interferes  with  parturition, 
by  impeding  the  passage  of  the  child's  head.  The  bladder  is 
pushed  down  by  the  distended  uterus  below  the  arch  of  the 
pubes,  forming  a  tumor  in  the  anterior  portion  of  the  vagina, 
which  feels  like  a  tense  bag,  of  a  globular,  ovoidal,  or  cushion- 
like shape,  and  the  volume  of  which  ranges,  according  to  the 
quantity  of  urine  present,  between  an  orange  and  a  large  fist. 


Sims's  OpeiatioQ  of  Elytrorraphy  ;  Sutures  in 
Place. 


348  MALPOSITIONS    OF    THE    BLADDER. 

In  sonic  instances  tlie  tumor  hangs  out  through  the  vulva, 
while  in  others  it  lies  partly  within  and  partly  without  the 
vagina.  The  protrusion  is  most  apt  to  take  place  during  the 
early  stages  of  lahor,  hefore  the  child's  head  has  reached  the 
pelvic  cavity,  and  appears  to  he  produced  hy  the  pressure  which 
the  descending  head  exerts  upon  the  upper  portion  of  the  dis- 
tended hladder.  As  the  lahor  advances,  the  displaced  organ  is 
still  farther  depressed  hy  the  contraction  of  the  uterus,  and  thus 
the  case  progresses  until  the  vaginal  passage  is  sometimes  totally 
occluded. 

The  symptoms  which  attend  the  affection,  in  this  event,  are 
variahle.  In  ordinary  cases,  there  is  merely  an  irritahle  condi- 
tion of  the  bladder,  with,  perhaps,  a  frequent  desire  to  urinate, 
and  some  difficulty  in  evacuating  the  water.  Occasionally  the 
patient  is  harassed  Avith  retention,  or  at  one  time  with  retention 
and  at  another  with  incontinence.  The  recumbent  posture 
usually  ameliorates  while  the  erect  aggravates  her  suffering. 
She  also  generally  complains  of  dragging  pains  in  the  pelvic 
region,  and  of  uneasiness  in  the  groin  and  perineum.  When 
the  prolapse  takes  phice  during  labor,  the  suffering  is  generally 
more  severe  ;  the  desire  to  urinate  is  much  more  urgent  and 
frequent;  the  patient  is  wholly  unable  to  pass  water;  the  tumor 
is  very  tense  and  painful ;  the  abdominal  muscles  contract 
spasmodically ;  and  there  is  a  most  distressing  dragging  sensa- 
tion in  the  hypogastrium,  the  parts  feeling  as  if  they  wanted  to 
come  away,  but  could  not. 

The  diagnosis  of  a  vaginal  cystocele,  complicating  parturition, 
is  generally  sufficiently  easy  ;  nevertheless,  cases  occur  in  which, 
for  the  want  of  proper  discrimination,  such  a  tumor  has  been 
punctured.  Chaussier  met  Avith  an  instance  in  which  a  large 
swelling  of  this  kind  was  mistaken  for  the  head  of  a  child. 
The  patient  was  in  labor,  and  her  attendant  was  on  the  point 
of  opening  the  tumor  for  the  purpose  of  extracting  the  child, 
when  the  celebrated  Frenchman  arrived  and  recognized  the 
disease.  A  case  is  mentioned  by  Dr.  Hamilton  where  the 
prolapsed  bladder  was  actually  punctured,  under  the  supposi- 
tion that  it  was  nothing  but  the  bag  of  the  ovum ;  and 
Merriman,  as  already  intimated,  records  one  where  a  similar 
blunder  was  committed  under  the  belief  tliat  the  swelling  was 
a  hydrocephalic  head.     These  examples,  the  number  of  which 


INVERSION    OF    THE    BLADDEE.  349 

might  be  easily  multiplied,  are  sufficient  to  show  how  important 
it  is  for  the  practitioner  to  have  a  correct  knowledge  of  this 
disease.  The  opening  of  a  prolapsed  bladder  might  readily 
produce  a  bad  fistule,  and  even  destructive  inflammation. 

The  characteristic  signs  of  the  aftection  are,  flrst,  the  sudden 
development  of  the  tumor ;  secondly,  the  peculiarity  of  its 
situation  at  the  anterior  wall  of  the  vagina ;  thirdly,  its  soft 
and  fluctuatiug  consistence ;  and  fourthly,  its  diminution,  or 
eflacement  under  compression,  and  the  desire  which  the  patient 
feels,  when  it  is  thus  acted  upon,  to  make  water.  During 
parturition,  the  tension  of  the  swelling  is  increased  during  the 
contraction  of  the  uterus  and  lessened  during  its  relaxation. 
Moreover,  by  introducing  the  catheter,  which,  however,  is 
sometimes  very  difficult,  the  bladder  may  usually  be  completely 
emptied,  and,  consequently,  the  bag  made  to  disappear. 

The  treatment  of  this  form  of  cystocele  consists  in  drawing 
off  the  urine  by  means  of  a  male  catheter,  with  the  point 
directed  downwards  towards  the  base  of  the  tumor.  The 
common  female  catheter  is  not  sufficiently  curved,  and  is, 
therefore,  unsuited  to  such  a  contingency.  The  patient  lying 
on  her  back,  with  the  limbs  elevated  and  separated  from  each 
other,  the  operation  is  performed  during  the  repose  of  the 
womb,  lest  the  pressure  of  the  child's  head  against  the  ex- 
tremity of  the  instrument  should  occasion  mischief.  If 
catheterism  be  found  impracticable,  as  it  sometimes  is,  under 
such  circumstances,  the  accoucheur,  introducing  several  of  his 
fingers  into  the  vagina,  waits  until  the  uterine  pains  go  otf, 
and  then,  pressing  against  the  inferior  surface  of  the  tumor,  he 
pushes  it  upwards  behind  the  pubic  bones,  and,  consequently, 
towards  the  superior  strait  of  the  pelvis.  Held  in  this  situation 
until  there  is  a  return  of  the  pains,  there  will  be  no  probability 
of  a  reproduction  of  the  swelling.  Chloroform  should  be  ad- 
ministered to  quiet  the  violent  spasmodic  contraction  of  the 
abdominal  muscles. 

Sect.  II.— INVERSION  OF  THE  BLADDER. 

Inversion  and  protrusion  of  the  bladder  at  the  urethra,  in  the 
form  of  a  red,  vascular,  and  highly  sensitive  tumor,  is  exclusively 
confined  to  the  female  sex  ;  the  great  length,  peculiar  shape,  and 


ooO  MALPOSITION'S    OF    THE    BLADDER. 

narrowness  of  the  uretlira  in  tlie  male  not  admitting  of  its  occur- 
rence, except,  perhaps,  in  a  very  partial  manner.  Two  distinct 
forms  of  the  aftection  are  met  with  in  practice,  the  complete  and 
incomplete;  the  former  consisting  in  an  inversion  of  all  the 
tunics  of  the  hladder,  while,  in  the  latter,  the  inversion  is  limited 
exclusively  to  the  mucous  memhrane.  The  partial  variety  is 
much  more  common  than  the  complete,  of  which,  in  fact,  only 
a  few  cases  are  on  record. 

a.  The  incomplete  variety  is  almost  peculiar  to  infants,  in 
which  it  usually  appears  as  a  florid  tumor,  rarely  larger  than  a 
chestnut,  between  the  labia.  In  a  case  recorded  by  ]!!^oel,^  it 
occurred  as  a  tumor  of  the  volume  of  a  pullet's  egg,  which  hung 
from  the  urethra  in  the  form  of  a  very  thin,  transparent  bag, 
tilled  with  a  clear,  limpid  fluid.  The  child  had  been  tormented 
for  several  days  with  retention  of  urine,  attended  with  frequent 
convulsions.  On  dissection,  the  ureters  were  found  to  be 
enormously  dilated ;  and  the  yirotrusion  to  be  formed  by  the 
mucous  membrane  of  the  bladder,  which  had  been  separated 
from  the  muscular  coat  of  the  organ  b}'  the  gradual  insinuation 
of  the  urine  between  them,  on  account  of  ol:»struction  to  the  flow 
of  urine  from  the  ureters.  In  an  example  of  partial  protrusion, 
mentioned  by  Hoin,^  the  tumor,  evidently  formed,  as  was  supposed 
In'  this  writer,  of  the  mucous  membrane  of  the  neck  of  the  bladder, 
was  nearly  of  the  shape  and  size  of  the  third  phalanx  of  the  little 
finger.  It  appeared  to  have  been  produced  by  the  violent  strain- 
ing which  the  patient,  a  woman,  twenty-five  years  of  age,  was 
obliged  to  make  to  void  her  urine,  which  was  frequently  retained. 
It  remained  several  days  in  the  same  situation,  and  finally  slipped 
up  of  its  own  accord. 

To  this  variety  of  the  disease  belongs  the  remarkable,  if  not 
unique  ease  of  Dr.  J.  Bamberger,^  of  a  man  who  was  for  a  long 
time  afllicted  with  anal  fistule,  accompanied  by  a  tumor  as  large 
as  a  hen's  ogg,  in  the  perineum,  consequent  upon  a  fall  upon  this 
region  a  number  of  years  previously.  He  was  unable  to  retain 
his  urine,  which  constantly  dribbled  away,  and  thus  greatly 
aggravated  his  sufterings.     Whenever  an  attempt  was  made  to 

I  Memoires  de  I'Acad.  Royale  de  Chir.,  t.  ii.  p.  23.     Paris,  1819. 
^  Essais  siir  les  Hernies,  p.  343. 

»  Diss,  de  Intussuscep.  Membr.  Urethrfe  Int.  ex  Prolapsu  Ejiisdem.     Wiice- 
burg,  1795. 


INVERSION    OF    THE    BLADDER.  351 

pass  a  catheter,  the  point  of  the  instrument  was  invariably 
arrested  bj'  the  tumor.  An  examination  of  the  body  revealed 
the  following  circumstances.  The  right  ureter,  as  well  as  the 
right  pelvis  of  the  kidney,  was  widely  dilated  in  its  whole  length, 
the  coats  of  the  bladder  were  very  thick  and  muscular,  and  the 
urethra  was  greatly  expanded  for  a  short  distance  beyond  the 
1)ulb,  where  it  was  observed  to  be  abnormally  narrow.  Into 
this  contracted  portion  projected  a  fold  of  the  lining  mend^rane 
of  the  bladder,  in  the  form  of  an  acorn,  with  a  small  opening 
capable  of  admitting  a  silver  probe. 

The  immediate  cause  of  this  affection  would  appear  to  be  a 
relaxed  and  weakened  state  of  the  mucous  membrane  of  the 
bladder,  attended  with  great  dilatation  of  the  urethra.  The 
exciting  causes  are  violent  and  frequent  straining,  such  as 
accompanies  various  impediments  to  the  evacuation  of  the  urine 
and  feces,  and  protracted  and  violent  cough. 

In  the  treatment  of  this  form  of  inversion  aud  prolapse,  the 
circumstances  to  be  mainly  attended  to  are,  first,  to  enjoin  strict 
recumbency,  not  for  a  week  or  month,  but  for  a  long  time; 
secondly,  to  reduce  the  tumor  carefully,  and  to  counteract  after- 
wards any  tendency  to  protrusion  by  the  frequent  use  of  the 
catheter,  and  astringent  washes  and  injections ;  and,  thirdly,  to 
correct  the  general  health  by  chalybeate  tonics  and  other  means. 
The  bowels  should  be  maintained  in  a  soluble  condition,  and  the 
urine  should  be  voided  in  the  recumbent  posture,  the  patient 
lying  on  her  side  or  back.  Excision  of  the  protruded  parts 
should  be  studiously  avoided,  as  it  might  lead  to  fatal  results. 

jS.  Of  the  complete  variety  of  inversion  and  prolapse  of  the 
bladder,  there  are,  so  far  as  my  information  extends,  only  seven 
well-authenticated  cases  on  record.  Of  these,  the  first  occurred 
in  the  practice  of  Mr.  Percy,  by  whom  it  was  communicated  to 
Mr.  Chopart.^  The  others  were  met  with  by  Dr.  Thomson,^  Dr. 
Murphy ,3  Mr.  Crosse,"  Dr.  Lowe,^  Dr.  Beatty,"  and  Mr.  Croft.^ 

'  Traite  des  Maladies  des  Voies  Urlnaires,  t.  i.  p.  399.     Paris,  1830. 

2  London  Lancet,  vol.  i.,  1875,  p.  46. 

3  London  INIedical  GazeUe,  vol   xi.,  1833,  p.  o25. 

*  Trans,  of  the  Provincial  Med.  Assoc,  vol.  xiv.,  1846,  p.  185. 

5  London  Lancet,  1863,  vol.  i.  p.  250. 

•>  McClintock,  Clinical  Memoirs  on  Diseases  of  Women,  1863,  p.  239. 

7  St.  Thomas's  Hospital  Reports,  N.  S.  vol.  ii.,  1871,  p.  195. 


352  MALPOSITIONS    OF    THE    BLADDER. 

Of  these  seven  cases,  the  first  occurred  in  a  very  fat  abhess,  fifty- 
two  years  of  age,  who  was  habitually  affected  with  a  cougli  ; 
the  second  was  due  to  excessive  straining  from  acute  cj^stitis,  in 
a  woman  upwards  of  forty ;  while  the  remainder  were  confined 
to  infants  between  the  ages  of  fourteen  months  and  four  years. 
In  the  instance  of  Dr.  Lowe  the  child  had  been  subject  to  inconti- 
nence of  urine  from  its  Ijirth ;  and  from  the  time  it  was  two  or 
three  days  old  the  tumor  had  been  observed  to  protrude  during 
a  fit  of  coughing  or  straining.  The  probability  is  that  a  con- 
genitally  relaxed  and  weakened  condition  of  the  muscular  fibres 
of  the  neck  of  the  bladder  and  the  urethra  is  the  essential  cause 
of  tlie  trouble,  and  that  the  inversion  takes  place  during  fits  of 
crying,  coughing,  sneezing,  or  straining  at  stool.  In  all  of  the 
cases  the  urethra  was  greatly  dilated. 

The  case  of  Mr.  Croft  is  peculiar  from  the  fact  that  during  the 
struggles  that  were  made  in  the  examination  the  bladder  gave 
way  at  a  minute  point  on  its  most  prominent  as[)ect,  followed 
by  the  escape  of  a  small  quantity  of  a  clear,  straw-colored  fluid, 
which  responded  to  none  of  the  tests  for  urine,  and  by  partial 
collapse  of  the  tumor.  Mr.  Croft  is  of  the  opinion  that  the 
inverted  bladder  carried  its  partial  peritoneal  covering  with  it, 
which,  becoming  constricted  by  the  meatus,  poured  out  a  serous 
fluid.  Violent  expulsive  eftbrts  of  the  abdominal  muscles  at  last 
caused  the  tiny  rupture  which  he  witnessed.  This,  however, 
did  not  give  rise  to  any  bad  consequences. 

It  is  of  great  moment  that  this  variety  of  tumor  should  not 
be  confounded  with  other  affections,  as  vascular,  polypoid,  and 
other  growths  occurring  in  this  situation.  It  is  evident  that  an 
error  of  diagnosis  might  be  productive  of  the  most  serious  con- 
sequences. In  the  case  of  Mr.  Murphy,  the  tumor  was  mistaken 
by  another  practitioner  for  a  prolapse  of  the  rectum,  a  view  in 
which  that  gentleman  himself  was  at  first  inclined  to  coincide ; 
and  it  was  not  until  after  the  most  patient  and  thorough  exami- 
nation, and  the  detection  of  the  orifices  of  the  ureters,  which 
were  brought  into  view  by  pulling  the  swelling  gently  down- 
wards, that  he  arrived  at  a  satisfactory  conclusion.  In  the  in- 
stance of  Mr.  Crosse,  the  professional  attendant  supposed  the 
protrusion  to  be  a  vascular  tumor,  on  which  account  he  thought 
it  might  be  removed  by  ligature,  which  he  was  on  the  point  of 


INVERSION    OF    THE    BLADDER.  353 

applying,  when,  fortunately  for  both  patient  and  himself,  the 
true  nature  of  the  malady  was  detected. 

The  most  important  signs,  in  a  diagnostic  point  of  view,  are, 
the  presence  of  a  pyriform,  red,  florid,  vascular,  soft,  elastic, 
reducible  tumor,  about  the  size  of  a  walnut,  situated  below  the 
clitoris,  and  between  the  labia,  which  may  become  injected  and 
increase  in  size  on  crying  or  straining ;  more  or  less  dysuria  or 
incontinence  both  before  and  after  its  appearance;  the  ureters 
exposed  or  rendered  visible  by  gentle  traction  on  the  protrusion ; 
and  unimpairment  of  the  general  health.  In  making  an  exami- 
nation, the  patient  should  ahvays  be  placed  recumbent,  with  the 
thighs  somewhat  flexed  on  the  pelvis,  and  separated  from  each 
other;  the  pudendal  lips  should  then  be  held  apart,  and  the 
tumor  carefull}'  inspected  at  its  point  of  attachment,  which  is 
always  comparatively  narrow,  and  appears  as  if  it  "were  prolonged 
into  the  urethra.  A  polypoid  or  papillary  tumour,  or  sarcoma- 
tous growth,  affections  which  are  liable  to  occur  in  this  situa- 
tion, may  usually  be  easily  distinguished  by  tlieir  history,  by 
their  comparatively  firm  consistence  and  solid  feel,  by  their 
irreducibility,  hy  the  presence  of  the  urethra  in  front  of  the 
tumor,  and,  finally,  by  the  character  of  the  accompanying  local 
distress,  which  is  sometimes  very  severe,  and  may,  if  persistent, 
seriously  undermine  the  general  health. 

In  the  reduction  of  the  tumor,  the  patient  is  placed  upon  her 
back,  the  head  and  shoulders  are  elevated,  and  the  thighs,  flexed 
upon  the  pelvis,  are  widely  separated  from  each  other.  The  labia 
are  then  held  apart  by  an  assistant,  wdiile  the  surgeon  applies 
his  fingers,  previously  oiled,  to  the  surface  of  the  tumor,  and 
pushes  up  that  part  of  it  first  which  came  down  last,  the  pressure 
being  maintained  steadily  but  gently  until  the  whole  of  it  has 
slipped  up  behind  the  pubic  symphysis.  When  the  swelling  is 
bulky  and  of  long  standing,  it  may  be  necessary  to  assist  these 
efforts  by  means  of  a  catheter  a[tplied  to  the  fundus  of  the  blad- 
der, and  carried  up  in  the  direction  of  the  urethra,  as  Avas  done 
so  successfully  by  Dr.  Murphy. 

^When  the  parts  are  restored,  the  patient  should  be  obliged  to 
observe,  for  some  time,  the  recumbent  posture  ;  the  urine  should 
be  drawn  ott' several  times  a  day  with  the  catheter;  and,  if  the 
tendency  to  protrusion  be  considerable,  a  compress,  confined  by 
a  T-bandage,  should  be  worn  upon  the  orifice  of  the  urethra. 
2'd 


354  MALPOSITION'S    OF    THE    BLADDEK. 

"When  the  patient  gets  up,  she  should  wear  an  abdominal  truss, 
to  aftbrd  tone  and  support  to  the  hypogastric  region. 

In  view  of  the  loss  of  tone  of  the  muscular  fibres  of  the  neck  of 
the  bladder  and  the  urethra,  faradization  should  first  be  resorted 
to ;  but  when  the  urethra  is  much  dilated,  and  there  is  persis- 
tent incontinence  of  urine,  an  operation  may  become  necessary 
•for  the  purpose  of  diminishing  its  calibre.  The  inferior  portion 
of  the  tube  may  be  divested  of  its  mucous  membrane,  after  which 
the  raw  surfaces  may  be  approximated  by  several  points  of  the 
interrupted  suture,  care  being  taken  to  draw  off  the  urine  several 
times  a  day  until  the  consolidation  is  perfected.  To  effect  the 
same  object,  Dr.  Lowe  applied  the  actual  cautery  five  times  in 
eleven  months.  There  was  no  relapse  of  the  affection ;  but  slight 
incontinence  remained. 


CHAPTER    XVI. 

MALFORMATIONS  AND  IMPERFECTIONS  OF  THE  BLADDER. 

Malformations  of  the  bladder  are  rare,  and,  with  two  excep- 
tions, in  a  practical  point  of  view,  not  very  important.  They 
may  be  arranged  under  the  following  heads:  1.  Absence  of  the 
bladder;  2.  Bilobation,  or  multiplication  of  the  organ;  3.  Ex- 
strophy, or  congenital  eversion  ;  4.  Patent  urachus. 

Sect.  I.— ABSENCE  OF  THE  BLADDER. 

Absence  of  the  bladder  has  been  observed  only  in  a  few  in- 
stances ;  but  when  the  defect  exists,  the  ureters  open  into  the 
rectum,  the  urethra,  the  vagina,  or  in  the  vicinity  of  the  navel. 
jSTauche'  has  recorded  an  instance  of  the  last  occurrence,  and, 
still  more  recently,  Mr.  Buck^  has  described  the  case  of  a  person 
who  passed  for  twenty-three  years  as  a  female,  in  which  there 
was  a  congenital  malformation  of  the  penis,  scrotum,  testes,  and 
pelvic  bones,  and  a  complete  absence  of  the  bladder,  the  urine 
constantly  escaping  at  an  ulcerated  point,  which  corresponded  to 
the  umbilicus,  by  two  small  apertures  which  denoted  the  open- 
ings of  the  ureters. 

When  the  ureters  terminate  in  the  rectum,  the  part  is  con- 
verted into  a  true  cloaca,  as  in  birds  and  reptiles.  Richardson 
has  published,  in  the  seventh  volume  of  the  Philosophical  Society 
of  London,  the  history  of  a  3'outh  who  lived  seventeen  years 
without  ever  having  urinated  by  the  penis.  He  passed  all  his 
water  by  the  anus,  and  the  only  inconvenience  which  he  expe- 
rienced was  a  slight  but  persistent  diarrhoea.  Haller^  cites 
several  examples  of  the  insertion  of  the  ureters  into  the  vagina. 

A  singular  case  of  this  deficiency  was  observed  some  years 
ago,  by  Dr.  B.  J.  Raphael,  of  New  York.  The  subject  was  a 
full-groM-n,  healthy-looking  infant,  which,  at  birth,  presented  the 

'  Maladies  de  la  Vessie,  p.  9.  *  London  Lancet,  vol.  ii.,  18G0,  p.  564. 

3  Element  Physiol.,  t.  vii.  p.  297. 


356  MALFORMATIONS    AND    IMPERFECTIONS. 

following  appearances.  There  was  a  tumor,  about  the  size  of  a 
hen's  C2;g,  at  the  umbilicus,  which  evidently  contained  intestine, 
and  which  could  be  easily  reduced,  but  always  returned  the 
moment  that  the  pressure  employed  for  that  purpose  was  discon- 
tinued. The  anus  was  imperforate,  the  testes  had  not  descended, 
and  the  penis  and  scrotum  existed  merely  in  a  rudimentary  state. 
The  posterior  fontanelle  was  absent.  The  child  died  at  the  end 
of  nine  days.  On  dissection,  the  tumor  above  mentioned  was 
found  to  contain  nearly  the  whole  mass  of  the  small  intestines, 
which  were  adlierent  to  each  other,  and  terminated  in  the 
umbilical  sac,  where  there  was  a  discharge  of  meconium  through 
an  opening  made  by  ulceration.  The  entire  colon  was  wanting. 
No  trace  of  a  bladder  could  anywhere  be  detected.  The  left 
kidney  occupied  the  usual  position,  but  the  right  Avas  situated 
in  the  riglit  side  of  the  pelvis.  Both  ureters  terminated  in  the 
sac  containing  the  small  intestines.  The  sacrum  was  very  broad, 
and  filled  up  the  space  between  the  branches  of  the  ischiatie 
bones,  while  the  coccyx  was  prolonged  forwards  to  an  unnatural 
extent,  and  thus  served,  along  with  the  bones  just  mentioned, 
to  form  the  anterior  wall  of  the  pelvis,  the  pubic  bones  being 
absent. 

A  few  instances  are  related  in  which  the  ureters  were  directly 
continuous  with  the  urethra.  Of  these,  one  of  the  best  authen- 
ticated is  that  of  Binninger,'  who  observed  it  in  the  body  of 
Abraham  Clef,  which  he  examined  in  the  presence  of  several 
surgeons.  The  bladder  was  totally  wanting.  A  probe  intro- 
duced into  the  uretlira  could  be  readily  passed  alternately  into 
the  ureters,  and  from  the  ureters  into  the  urethra  ;  thus  proving, 
beyond  all  doubt,  that  there  was  no  intermediate  sac.  The 
kidneys  were  unusually  large,  and  free  from  calculous  concre- 
tions, although  Clef  had  voided  one  some  time  before  his  death. 
Schmidt^  met  with  a  case  of  absence  of  the  bladder  in  a  female 
thirty -two  years  of  age,  who  suffered  from  incontinence  of  urine 
since  lier  twelfth  year.  The  right  ureter  opened  at  the  meatus. 
Floury^  has  also  quite  recently  recorded  the  case  of  a  girl  who 
had  menstruated  for  two  years,  in  which  the  ureters  terminated 
in  the  cul-de-sac  of  the  urethra  wliich  was  an  inch  and  a  half 
long. 

'  O^s.  Med.,  t.  2,  c.  3.  2  London  Lancet,  vol,  i.  1860,  p.  325. 

3  Gaz.  Hebd.,  No.  G,  1874. 


BILOBED    BLADDER.  357 

Sect.  II.— BILOBED  BLADDER. 

The  bladder  has  been  found  divided  into  two  or  more  com- 
partments, the  result  of  a  congenital  defect.  The  anomaly  is 
exceedingly^  rare,  the  great  majority  of  reported  cases  of  double 
or  multiple  bladders  being  merely  instances  of  sacculation  from 
disease.  In  the  latter  event  the  muscular  tunic  does  not  enter 
into  the  composition  of  the  supplementary  organ.  The  internal 
septum  upon  which  this  arrangement  depends  is  generallj^  situ- 
ated transversely,  but  occasionally  it  is  directed  obliquely,  or 
even  vertically.  Of  the  latter  variety  an  interesting  example  is 
recorded  by  Blasius.'  The  bladder  of  a  man  who  died  of  phthisis 
was  divided  in  the  direction  of  its  length  into  two  equal  por- 
tions, by  a  septum  which  extended  from  the  superior  part  of  the 
reservoir  to  its  neck.  Each  compartment  had  a  distinct  ureter. 
Frank^  met  with  a  similar  instance.  During  life,  a  tumor  was 
perceptible  on  each  side  of  the  linea  alba,  both  of  which  disap- 
peared on  micturition.  An  extraordinary  example  of  Inpartite 
bladder  is  reported  by  Angelo  Scarenzio.^  A  young  man,  nine- 
teen years  of  age,  with  hypospadias  and  cleft  prei)uce,  had 
undergone  six  lithotrity  operations,  when,  in  consequence  of  the 
impaction  of  fragments  of  the  stone,  he  was  sul»jected  to  lateral 
lithotomy  six  months  after  the  first  sitting.  Death  resulting 
at  the  expiration  of  two  months,  the  bladder  was  found  to  be 
divided  by  a  longitudinal  septum,  which  was  the  seat  of  an 
opening  through  which  the  two  lialves  communicated. 

In  a  man,  fifty-eight  years  of  age.  Professor  Scibelli,*  of  l!^aples, 
found  a  triple  bladder.  The  supplementary  organs,  which  were 
Avell  provided  with  a  muscular  tunic,  and  were  continuous  with 
the  ureters,  communicated  with  the  normal  bladder  by  two 
openings  seated  in  its  right  lateral  wall. 

Mr.  Beach,^  in  the  case  of  a  girl,  five  years  of  age,  met  with 
a  bladder  containing  a  pouch  opening  into  a  third  ureter,  Avhich 
communicated  with  the  enlarged  right  kidney  by  a  cavity  with 

'  Observ.  Med.  Rarior,  Ciirn.  Fig.  ob.  19. 
^  Seydel.  Arcb.  der  Heilkunde,  1865,  p.  385. 

*  Aunali  Universali  di  Mediciua,  18G0,  aud  Gurlt's  Jabrcsbericht  fur  1800, 
1861,  p.  414. 
'  Med.-Cbir.  Rev.,  Oct.  1864,  p.  328. 
'  Trans.  Patb.  Soc.  London,  vol.  xxv.  p.  185. 


358  MALFORMATIOXS    AN'D    IMPERFECTIONS. 

smooth  walls,  but  shut  oft'  from  the  remainder  of  the  kidney. 
A  still  more  remarkable  example  of  malformation,  however,  is 
recorded  by  Moliuetti,'  Here  the  individual,  a  female,  had 
iive  bladders,  iive  kidneys,  and  six  ureters,  of  which  two  were 
inserted  into  the  largest  reservoir,  while  the  remainder  termi- 
nated each  in  one  of  the  small  sacs,  which  discharged  their  con- 
tents by  special  ducts  into  the  main  organs.  This  extraordinary 
number  of  bladders  was  the  result  altogether  of  an  original  vice 
of  formation  and  not  of  disease. 

A  case  of  congenital  malformation  of  the  bladder,  of  a  very 
singular  and  unusual  character,  was  published  some  years  ago 
by  Dr.  C.  P.  Johnson,^  Professor  of  Anatomy  and  Physiology  in 
the  Medical  College  at  Richmond,  Virginia.  It  occurred  in  a 
male  child,  eight  months  of  age,  who  had  sufl'ered  for  several 
weeks  previously  to  his  death  from  violent  paroxj^sms  of  pain 
in  the  hypogastric  and  umbilical  regions.  The  chief  point  of 
interest  was  an  abnormal  pouch,  which,  arising  by  a  narrow 
pedicle  from  the  lower  and  back  part  of  the  bladder,  at  the  place 
naturally  occupied  by  the  right  seminal  vesicle,  passed  along 
the  posterior  wall  of  the  bladder,  about  two  inches  above  its 
upper  border.  It  Avas  qbout  ten  lines  in  diameter,  of  an  irregu- 
larly cylindrical  shape,  hollow,  and  of  the  same  structure  as  the 
bladder,  with  which  it  communicated  by  a  small  aperture  just 
within  and  below  the  orifice  of  the  right  ureter.  The  pouch,  at 
the  time  of  the  dissection,  was  found  to  be  tilled  with  urine. 
The  Ijladder  was  of  the  natural  size  and  form  ;  and  the  prostate 
gland,  the  left  seminal  vesicle,  and  the  two  ureters  occupied  their 
usual  position. 

Sect.  Ill  —EXSTROPHY  OF  THE  BLADDEE. 

By  far  the  most  frequent  and  distressing  malformation  of  the 
bladder,  is  exstrophy  or  congenital  extroversion,  a  condition 
which  consists  essentially  in  a  fissure  of  the  anterior  wall  of 
the  viscus  and  a  hernial  protrusion  of  its  posterior  and  lower 
part  through  a  deficiency  in  the  linea  alba  below  the  navel 
and   between  the  straight  muscles  of  the  abdomen,  reaching 

'  Diss.  Anat.  Path.,  lib.  G.  cap.  7. 

«  Medical  Examiuer  aud  Record  of  Medical  Science,  July,  1850,  p.  381. 


EXSTROPHY    OF    THE    BLADDER. 


359 


as   low   flown  as    the   genital   organs 


The  affection,  which 
takes  place  during  the  fourth  week  of  foetal  life,  and  is  due  to  a 
want  of  union  of  the  allantois,  is  met  with  in  several  degrees  of 
severity,  so  that  it  may  be  regarded  as  partial  or  complete,  in 
accordance  with  the  extent  of  the  coexisting  defects  in  the  pubic 
bones  and  the  genital  apparatus.  In  the  milder  grades,  the 
umbilicus  is  well  formed,  and  the  cleft  in  the  abdominal  walls 
is  so  slight  that  a  more  or  less  extensive  strip  of  integument 
exists  between  that  protuberance  and  the  upper  limit  of  the 
protrusion.  In  other  cases,  the  urethra  and  genital  organs  are 
normal,  and  the  symphysis  is  present,  although  it  is  membranous 
and  delicate,  as  in  those  recently  reported  by  Dr.  Cheever^  and 
Dr.  Bigelow.2  In  another  class  of  cases,  and  they  are  still  less 
severe  than  the  preceding  forms,  the  bladder  is  only  cleft  at  its 


Fiff.  109. 


Exstrophy  of  the  Bladder,    a.   Everted  bladder.    b,1>.  Orifices  of  the  ureters,     c    Peuis  williout 
ureilira,     0,  d.  I'ubic  syinpliysis.     e.  Scrotum  and  testis.    /.   (Jougeuital  inguiual  lieruia. 

upper  portion,  and  its  posterior  wall  protrudes  above  the  pubes, 
the  genitals,  the  urethra,  and  pubic  symphysis  being  perfect. 
In  the  complete  form  of  the  affection,  of  Avhich  a  good  represen- 
tation is  afforded  in  fig,  109,  taken  from  a  patient  upwards  of 


'  Boston  Med.  and  Surg.  Journ.,  Feb.  11,  1875. 


2  Ibid.,  Jan.  6,  1870. 


360  MALFORMATIONS    AND    IMPERFE  CTIOXS. 

twenty  years  of  age,  tlie  pelvis  is  deformed,  and  the  genito- 
urinary apparatus  is  in  a  more  or  less  rudimentary  condition. 

The  protruded  hladder  presents  considerable  diversity  both 
as  it  respects  its  form,  size,  and  color.  In  general,  it  is  some- 
what ovoidal,or  globular;  but, occasionally,  it  is  very  irregular, 
or  nearly  flat.  Its  volume  is  greatly  influenced  by  the  age  and 
position  of  the  subject.  In  the  child,  it  rarely  exceeds  that  of  a 
walnut,  while  in  the  adult,  when  it  has  attained  its  maximum 
develo[)ment,  it  may  be  as  big  as  a  fist,  or  a  goose's  egg.  Very 
small  when  the  subject  is  recumbent,  it  becomes  quite  promi- 
nent, from  being  pushed  forward  by  the  abdominal  viscera,  when 
he  stands  up,  coughs,  sneezes,  or  exerts  himself.  The  surface  of 
the  tumor  is  of  a  bright-red  color,  and  is  constantly  covered 
with  a  mucous  secretion,  which  protects  it,  in  some  degree,  from 
the  injurious  impression  of  the  atmosphere.  In  elderly  subjects, 
the  part  is  sometimes  j^artially  invested  with  a  cutaneous  pelli- 
cle, in  consequence  of  which  it  is  much  less  sensitive,  or  irritable, 
than  in  infancy,  childhood,  and  adolescence,  in  which  it  is  gene- 
rally very  tender,  and  apt  to  bleed  on  the  slightest  touch.  The 
orifices  of  the  ureters,  generally  situated  at  the  inferior  part  of 
the  tumor,  are  usually  marked  each  by  a  small  conical  eminence, 
from  which  the  urine  constantly  dribbles,  rendering  the  person, 
even  if  very  cleanh*  in  his  habits,  uncomfortable  to  himself,  and 
disgusting  to  those  around  him.  The  distance  between  the  two 
apertures  varies  from  one  to  two  inches,  according  to  the  age  of 
the  subject. 

In  most  cases,  there  is  a  separation  of  the  pubic  bones,  or, 
more  properly  speaking,  an  absence  of  their  bodies.^  The  inter- 
val between  them  varies,  in  difterent  cases,  from  two  and  a  half 
to  five  inches,  according  to  the  age  of  the  subject  and  the  width 
of  the  pelvis ;  and  is  occupied  by  a  strong,  dense,  ligamentous 
substance,  by  which  the  gap  is  effectually  closed.  The  pelvis  is 
generally  broader  and  more  shallow  than  in  ordinary  individuals, 
and  the  thighs  are  usually  wider  apart.  A  very  common  occur- 
rence is  inguinal  hernia,  sometimes  on  one,  and  sometimes  on 
both  sides. 

The  penis,  always  preternaturally  short  and  flattened,  is  gene- 

'  Cases  in  which  no  such  separation  existed  are  recorded  by  Denman.  Walker, 
Coates,  Roose,  and  other  writers  ;  but  thej'  appear,  on  the  whole,  to  be  rare. 


EXSTROPHY    OF    THE    BLADDER.  861 

rally  bent  backwards,  and  furnislied  with  an  imperfect  prepuce. 
The  cavernous  bodies,  attached  below  to  the  ischium,  as  in  the 
natural  state,  are  small  and  narrow,  and  are  not  alwaj's  united 
along  the  middle  line,  except  just  behind  the  head  of  the  penis. 
This  organ  is  sometimes  imperforate,  and  at  other  times  it  pre- 
sents a  gutter  along  its  upper  surface  for  the  lodgment  of  the 
lower  half  of  the  urethra.  When  this  is  the  case,  the  ^losterior 
part  of  the  canal  displays  the  verumontanum,  the  mouths  of  the 
ejaculatory  ducts,  and  the  orifices  of  the  prostatic  canals.  The 
prostate  gland  is  generally  present,  but  in  a  rudimentary  state. 

TJie  seminal  vesicles,  always  very  diminutive,  are  sometimes 
represented  by  two  small  tubercles.  Whatever  may  be  their 
volume,  they  are  invariably  situated  behind  the  inferior  part  of 
the  tumor.  The  ejaculatory  ducts  pursue  their  natural  route, 
but  are  unusually  small. 

The  scrotum  is  sometimes  completely  absent ;  at  other  times 
it  exists  merely  in  a  rudimentary  state.  In  the  latter  case,  it 
may  contain  the  testicles,  while  in  the  former,  these  organs  are 
either  lodged  in  the  groins,  or  in  a  cutaneous  bag  at  each  side 
of  the  tumor.  The  testicles  are  sometimes  normal ;  at  other 
times,  they  are  diminished  in  volume,  or  entirely  absent ;  tliis, 
however,  is  rare. 

The  rectum  is  commonly  natural,  both  in  its  situation  and 
dimensions  ;  sometimes  it  is  considerably  dilated,  and  sometimes, 
again,  it  is  so  much  contracted  as  to  give  rise  to  great  pain  and 
difficulty  in  defecation. 

The  sexual  appetite  varies  in  diiferent  individuals ;  being 
entirely  wanting  in  some,  very  weak  in  others,  nearly  normal  in 
some,  and  in  others,  again,  so  great  as  to  be  at  times  a  source  of 
positive  suftering.  A  remarkable  instance  of  the  latter  pecu- 
liarity is  given  by  Dr.  Henry  W.  Ducachet,  of  Kew  York,  in 
the  thi]"d  volume  of  the  American  Medical  Recorder.  It  oc- 
curred in  a  man,  aged  thirty  years,  whose  testicles  were  large 
and  well-formed,  but  the  penis  was  impervious,  and  not  more 
than  an  inch  and  a  half  in  length.  He  confessed  that  his  vene- 
real desires  were  frequent  and  tormenting.  Examples  of  a  simi- 
lar description  are  mentioned  by  other  writers.  The  emissions, 
in  most  cases,  are  imperfect,  and  the  erections  are  generally 
attended  with  a  sense  of  uneasiness,  if  not  actual  pain.  From 
the  small  size  of  the  penis,  and  the  peculiar  conformation  of 


362  MALFORMATIONS    AND    IMPERFECTIONS. 

the  urethra,  persons  affected  with  tliis  infirmity  are  necessarily 
incaj)able  of  procreating  the  species. 

In  the  female,  important  changes  are  noticed  in  the  genital 
organs.  The  clitoris  may  he  absent,  or  it  may  deviate  more  or 
less  from  the  normal  standard.  It  is  sometimes  situated  at  one 
side  of  the  median  lino,  unusually  small,  cleft,  or  wanting 
entirely.  The  urethra  is  generally  absent.  The  nymphne  are  dis- 
united, and  imperfectly  developed ;  the  pudendal  lips  are  either 
absent,  or  they  are  of  moderate  size,  and  covered  with  hair.  In 
the  latter  case,  the}'  extend  from  the  sides  of  the  tumor  towards 
the  anus,  without  uniting,  and  without  forming  what  is  called 
the  fourchette.  The  vagina  usually  exists  in  a  rudimentary 
state ;  being  prcternaturally  short,  narrow,  and  flattened,  with 
an  uncommonly  small  orifice,  which  has  sometimes  the  appear- 
ance of  a  transverse  slit  or  fissure.  The  uterus  is  sometimes 
absent,  sometimes  rudimentary,  sometimes  fully  developed.  In 
the  latter  case,  the  subject  may  menstruate,  and  conceive,  as  in 
the  interesting  cases  recorded  by  Thiebault'  and  Ay  res.^  In  the 
male,  on  the  contrary,  there  must  always  be  complete  impotence, 
on  account  of  the  peculiar  manner  in  which  the  ejaculatory  ducts 
open  upon  the  surface  of  the  tumor. 

Exstrophy  of  the  bladder  is  much  more  common  in  males  than 
in  females.  Of  18  cases  that  have  come  under  my  notice,  all, 
exce[)t  2,  were  males.  The  late  Mr.  Henry  Earle,^  of  London, 
in  a  clinical  lecture  puljlishcd  in  1832,  states  that,  in  examining 
the  various  authorities  upon  the  subject  up  to  that  period,  he 
had  found  GS  cases,  of  whicli  60  occurred  in  males.  M.  Isidore 
G.  St.  Ililaire,  who  has  carefully  examined  the  question  in  his 
Jlistoire  des  Anomalies  de  I'Organisation,  estimates  the  differ- 
ence to  be  in  the  ratio  of  four  to  one. 

Despite  their  constant  discomfort,  persons  affected  with  this 
deformity  may  live  for  many  years.  Head,  whose  case  is  well 
known  in  this  country,  and  from  whom  the  illustration  was 
taken,  is  now  upwards  of  forty  years  of  age ;  and  Flajani  has 
recorded  a  case  of  seventy. 

Exstrophy  of  the  bladder,  unless  the  patient   is  willing  to 

'  Journal  General  de  Medccine,  t.  xxxiv.  p.  178. 

2  Coni^^enital  Exstrophy  of  the  Urinary  Bladder,  etc.,  New  York,  1859. 

3  London  Medical  and  Surgical  Journal,  vol.  i.  p.  loQ.     1832. 


EXSTROPHY    OF    THE    BLADDER.  363 

assume  the  risk  of  an  autoplastic  operation,  is  utterly  irremedi- 
able ;  all  that  can  be  done  is  to  palliate  the  patient's  suffering 
by  attention  to  cleanliness,  and  by  the  use  of  a  closely-fitting 
flexible  gutta-percha  shield,  furnished  with  a  gum-elastic  bottle 
for  receiving  the  urine,  as  represented  in  fig.  112.  When  this 
cannot  be  obtained,  the  part  must  be  kept  constantly  covered 
with  a  thick,  soft  compress,  renewed  as  often  as  it  becomes  wet 
and  disagreeable.  The  skin  around  may  be  protected,  if  neces- 
sary, with  pomatum,  simple  cerate,  or  zinc  ointment. 

In  the  treatment  of  exstrophy  of  the  bladder  the  principal 
objects  aimed  at  are  either  to  establish  a  channel  for  the  con- 
veyance of  the  urine  from  the  bladder  to  the  rectum  or  perineum, 
or  to  cover  its  exposed  and  sensitive  mucous  membrane  with 
flaps  of  skin,  thereby  protecting  it  from  the  contact  of  the 
clothing,  and  pi'eventing  excoriation  of  the  surrounding  parts,  as 
well  as  facilitating  the  adjustment  of  an  apparatus  for  receiving 
the  urine. 

With  the  view  of  diverting  the  urine  into  the  rectum,  Mr. 
Simon,  of  St.  Thomas's  Hospital,  passed  threads  from  the  ureters 
into  the  viscus,  by  which  their  contiguous  walls  were  strangu- 
lated for  about  half  an  inch,  and  a  uretero-rectal  fistule  estab- 
lished two  inches  above  the  anus,  through  which,  however,  only 
a  portion  of  the  urine  passed  into  the  bowel.  Some  urine  con- 
tinued to  flow  by  the  vesical  openings  of  the  uretere,  notwith- 
standing two  attempts  were  made  to  close  them  with  the  twisted 
suture.  Violent  constitutional  symptoms  ensued,  and  for  a  time 
the  patient,  a  lad  of  thirteen,  was  in  great  danger;  but  he  sur- 
vived for  nearly  a  year,  when  he  died  of  disease  of  the  kidneys 
and  ureters.^  Mr.  Lloyd-  and  Mr.  Athol  Johnson^  subsequently 
attempted  to  effect  the  same  object  by  passing  a  skein  of  silk 
through  the  bladder  and  the  rectum,  but  both  patients  died  of 
acute  peritonitis,  the  result  of  a  wound  of  the  recto-vesical  pouch 
of  the  peritoneum.  With  a  view  of  avoiding  the  danger  of  open- 
ing the  peritoneal  cavity,  Mr.  Holmes^  has  suggested  throwing 
the  bladder  and  rectum  into  a  common  cloaca,  by  applying  in 

'  London  Lancet,  vol.  ii.  1852,  p.  25,  and  Trans.  Path.  Soc.  Loudon,  vol.  vi. 
p.  25G. 
2  London  Lancet,  vol.  ii.  1851,  p.  370. 

"  Holmes's  Surgical  Treatment  of  Children's  Diseases,  1868,  p.  148. 
*  Ibid.,  p.  148. 


364  MALFORMATIONS    AND    IMPERFECTIONS. 

the  two  ors'ans,  and  between  the  ureters,  into  which  bougies  are 
passed  to  prevent  their  closure,  the  blades  of  a  jiair  of  screw 
forceps,  which  are  gradually  tightened  until  the  intervening 
tissues  are  destroyed. 

It  is  very  questionable  whether  these  plans  to  establish  a 
vesico-rectal  communication,  even  if  they  should  be  completely 
successful,  would  place  the  patient  in  a  better  or  more  comfort- 
able condition  than  l)efore.  In  the  case  of  Eichardson,  referred 
to  at  page  355,  in  Avliieli  the  ureters  opened,  as  a  congenital  vice, 
into  the  rectum,  the  urine  gave  rise  to  such  constant  irritation, 
that  the  lad  sutfered  from  continued  diarrhoea.  Assuming,  how- 
ever, that  the  urine  could  be  retained  for  a  short  period,  its 
voidance  by  the  rectum  is  hardly  more  desirable,  or  more  agree- 
able, than  to  pass  it  in  the  way  usual  to  such  persons. 

Early  in  the  present  year  Dr.  Levis,^  in  the  case  of  a  boy 
thirteen  years  of  age,  made  an  attempt,  at  the  Pennsylvania 
Hospital,  to  establish  a  fistulous  communication  between  the 
bladder  and  the  perineum,  and  cover  in  the  bladder  by  a  plastic 
oi:)eration.  By  passing  a  needle  armed  with  a  stout  wire  through 
tlie  base  of  the  bladder  and  behind  the  scrotum,  a  track  was 
made,  and  graduall}-  enlarged  by  the  introduction  of  bougies 
until  its  calibre  was  half  an  inch.  Through  this  passage  all  the 
urine  escaped.  A  large  scrotal  flap  was  then  inserted  over  the 
bladder,  carrying  with  it  the  rudimentary  penis,  which  was  thus 
left  in  the  new  pouch.  Drainage  was  insured  by  the  retention 
of  a  soft  catheter,  introduced  through  the  artificial  urethra. 
Death  ensued  on  the  twelfth  day,  apparently  from  the  eftects  of 
protracted  nausea  and  vomiting. 

An  operation  on  a  more  limited  scale,  having  for  its  objects 
the  obtunding  of  the  sensibility  of  the  mucous  membrane  of  the 
bladder  and  j^reventing  its  excoriation,  has  been  practised  by 
Mr.  Bryant.^  This  consists  in  converting  the  exposed  mem- 
brane into  a  cicatrice  by  the  application  of  the  actual  canter}', 
care  being  taken  to  avoid  the  ureters. 

The  first  attempt  to  relieve  this  malformation  by  covering  in 
the  bladder  by  flaps  should  be  credited  to  Jules  Roux,^  of  Toulon, 
who,  in  1853,  united  a  scrotal  flap  to  one  drawn  down  from  the 

'  Medical  Times,  April  1,  1876.  «  Practice  of  Surgery,  p.  551. 

»  Union  Medicale,  1853,  114  and  115. 


EXSTROPHY    OF    THE    BLADDER. 


365 


umbilical  region,  but  both  almost  entireh'  perislied  from  gan- 
grene. A  short  time  afterwards,  Richard,^  of  Paris,  folded  an 
umbilical  flap  over  the  bladder,  and  covered  it  in  by  one  raised 
from  the  anterior  half  of  the  scrotum.  The  man  died  of  peri- 
tonitis on  the  ninth  day,  but  the  union  of  the  flaps  was  almost 
perfect. 

Of  the  diiferent  operations  practised  at  the  present  day  the 
best,  in  my  judgment,  is  that  of  Professor  Wood,^  of  London, 
for  females,  and  that  of  Dr.  F.  F.  Maur}',^  for  males.  In  the 
former  procedure,  represented  in  flg.  110,  from  Ashhurst,  an  um- 


Wood's  Operation  for  Exstrophy  of  the  Bladder. 

bilical  flap.  A,  is  reversed  over  the  bladder,  the  dissection  being 
carried  down  to  within  half  an  inch  of  the  viscus,  as  indicated 
I33'  the  dotted  line,  and  groin  flaps  B,  C,  are  brought  over  the 
umbilical  flap,  their  upper  edges  a  b,  a'  b'  coming  together  in 
the  middle  line.  In  this  way  the  raw  surfaces  of  the  flaps  are 
brought  in  contact,  while  the  inverted  one  prevents  the  escape 
of  urine  in  an  upward  direction. 

In  the  operation  of  Dr.  Maury,  which  is  an  extension  of  that 
of  Roux,  represented  in  tig.  Ill,  tlie  bladder  is  covered  by  a  flap 
taken  from  the  perineum  and  scrotum,  by  carrying  a  curvilinear 
incision  from  the  outer  third  of  Poupart's  ligament  across  the 


'  Gazette  Hebdom,  No.  26,  1854. 

2  Med.-Chir.  Trans.,  vol.  lii.  p.  85. 

3  Amer.  Journ.  Med.  Sci.,  July,  1871,  p.  154. 


366 


MALFORMATIONS    AND    IMPERFECTIONS. 


middle  of  the  perineum  to  a  eorresponding  point  on  the  opposite 
side.  This  flap  is  carefully  dissected  up,  to  avoid  wounding  the 
testicles  or  hernia,  should  the  latter  exist,  until  the  root  of  the 
penis  is  reached,  when  that  organ  is  slipped  through  a  small 


Fisr.  111. 


Maury's  Operation  for  Exstrophy  of  the  Bladder. 

ojjening  made  in  the  centre  of  the  flap,  through  which  the  urine 
issues  without  coming  in  contact  with  the  wound,  A  curvili- 
near incision  is  then  carried  across  the  abdomen,  and  a  short 
flap  dissected  up  for  about  one  inch,  under  which  the  scrotal 
flap,  with  its  cutaneous  surface  vivified,  is  slid,  and  attached 
by  several  points  of  a  modification  of  the  tongue  and  groove 
suture  of  Professor  Paucoast.^  In  this  way,  Dr.  Maury  has 
succeeded  in  two  instances,  not  only  in  forming  a  covering 
for  the  bladder,  but  also  in  curing  a  double  inguinal  hernia  by 
the  contraction  of  the  exposed  granulating  surfaces.  In  a  third 
case,  in  which  he  performed  this  operation,  sloughing  of  the  flaps 
occurred. 

Professor  Bigelow,^  of  Boston,  recently  devised  a  new  ope- 
ration b}'  which  the  raw  surfaces  are  brought  together,  with- 
out there  being  any  necessity  for  the  formation  of  an  umbilical 
flap.  The  exposed  mucous  membrane  of  the  bladder  having 
been  dissected  oft'  ae  far  down  as  the  ureters,  two  lateral  flaps, 
which  included  both  inguinal  regions,  were  united  by  sixteen 
silver  sutures  in  the  median  line  and  transversely  above  it.     The 


'  Vide  Gross's  Surgery,  oth  ed.,  vol.  ii.  p.  360. 

^  Boston  Med.  and  Surg.  Journ.,  vol.  xciv.,  Xo.  1,  1876,  p.  1. 


EXSTEOPHY    OF    THE    BLADDER. 


867 


Fiff.  113. 


patient  was  a  boy  of  six,  and  union  was  solid  in  about  two 
weeks. 

Whatever  operation  may  be  practised,  the  parts  should  be 
thoroughly  protected  afterwards  with  oiled  lint  or  oxide  of  zinc 
ointment,  and  the  patient  should  be  placed  almost  in  a  sitting 
posture,  with  the  knees  well  supported  by  pillows  to  insure 
relaxation  of  the  abdominal  walls.  The  diet  should  be  nourish- 
ing, but  unstimu1ating,and  the  bowels 
should  be  locked  up  with  opium.  A 
properly  adjusted  urinal,  tig.  112, 
should  be  worn  constantly  after  the 
union  is  perfect,  and  the  utmost  atten- 
tion must  be  bestowed  upon  cleanli- 
ness, injections  of  a  very  dilute  solu- 
tion of  nitric  acid  being  used  to  pre- 
vent phosphatic  deposit  on  the  hairs. 

The  first  successful  plastic  operation 
for  exstrophy  of  the  bladder  was  per- 
formed, in  1858,  by  Professor  Pan- 
coast,'  by  lateral  groin  flaps,  the 
cutaneous  surfaces  of  which  were 
turned  towards  the  viscus.  When 
union  and  cicatrization  of  the  parts 
were  complete,  a  very  large  scrotal 
hernia  of  the  right  side  was  found  to  unnai. 

be   entirely   cured.      The   patient,   a 

man,  twenty-eight  years  of  age,  unfortunately  died  of  pneumonia 
at  the  expiration  of  two  months  and  a  half.  Dr.  Ayres,  of 
Brooklyn,  nine  months  subsequently,  succeeded  not  only  in 
covering  the  bladder,  but  in  establishing  the  urethra  and  anterior 
fourchette  of  a  woman  of  twenty-eight,  who  had  previouslj-  been 
delivered  of  a  well-developed  child.  The  operation  is  not,  how- 
ever, by  any  means  devoid  of  certain  risks  and  dangers,  of  which 
the  most  common  are  erysipelas  and  sloughing  of  the  flaps  from 
defective  nutrition,  and  death  from  peritonitis,  pyemia,  or  ex- 
haustion. Of  53  cases  in  the  hands  of  Roux,  Richard,  Lefort, 
Michel,  Maisonneuve,  Billroth,  Hirschberg,  Ruggi,  Holmes, 
Wood,  Bryant,  Marsh,  Durham,   Wilkins,  Barker,  Pancoast, 


'  Nortli  Amer.  Med.-Cliir.  Review,  July,  18o9,  p   710. 


368  MALFORMATIOXS    AXD    IMPERFECTIONS. 

Ay  res,  Maury,  Asliluirst,  Levis,  Forbes,  Bigelow,  Clieever, 
IIodo;es,  and  King,  39  were  successful,  8  were  failures,  and  6 
were  fatal. 

A  condition,  very  similar  to  exstrophy  of  the  bladder,  is  the 
protrusion  of  the  entire  closed  organ  through  a  congenital  cleft 
of  the  linea  alba.  In  a  remarkable  example  of  this  malformation, 
occurring  in  a  lad  of  eight,  and  recorded  by  Dr.  Lichtheim,^  the 
viscus  formed  a  scarlet  tumor,  one  inch  and  a  fifth  in  diameter, 
which  was  attached  to  the  abdominal  deficiency.  The  pubic 
bones  were  separated  to  the  extent  of  two  inches,  the  intervening- 
space  being  closed  by  dense  ligamentous  tissue.  The  upper  sur- 
faces of  the  cavernous  bodies  were  cleft,  but  closed  in  by  mucous 
membrane,  which  extended  forwards  to  the  contracted  meatus. 
The  urine  was  all  passed  by  the  urethra,  which  pursued  its 
normal  course  behind  the  membranous  symphysis. 

Sect.  IV.— PATENT  URACHUS. 

The  urachus  sometimes  remains  pervious  for  a  long  period 
after  birth,  if  not,  indeed,  during  the  whole  of  life.  When  this 
is  the  case,  it  occasionall}-  forms  an  outlet  for  the  urine,  which 
is  discharged  in  part  or  entirely  at  the  umbilicus.  The  affection, 
which  has  been  noticed  in  infants  and  in  adults,  is  often  associ- 
ated with  some  obstacle  to  the  free  passage  of  the  urine  by  the 
natural  channel,  as  abnormal  contraction,  or  complete  atresia,  of 
the  orifice  of  the  bladder,  congenital  narrowing  of  the  urinary 
meatus,  imperforate  prepuce,  or  phimosis.  It  has  also  been 
known  in  this  condition  to  give  lodgment  to  urinary  concretions, 
as  in  the  case  of  a  man,  twenty-six  years  of  age,  related  by  Boyer, 
in  which  the  cavity  contained  twelve  minute  calculi. 

The  umbilical  orifice  is  usually  quite  narrow,  and  surrounded 
by  a  pale,  fungous  border,  giving  the  part  the  appearance  of  a 
small  tumor,  or  jjapillary  excrescence.  lu  some  cases  the  open- 
ing is  contained  within  the  margins  of  the  umbilicus,  and  is 
sufficiently  large  to  admit  of  the  insertion  of  the  finger.  Occa- 
sionally an  instrument  can  be  readily  passed  through  the  ure- 
thra, across  the  bladder,  into  the  abnormal  aperture. 

The  treatment  of  vesico-urachal  fistule  is  sufficiently  simple. 

'  Langcnbeck's  Aicliiv,  Bd.'xv.  p.  471. 


PATEXT    URACHUS.  369 

In  general  it  is  only  necessary  to  remove  the  exciting  cause,  as 
a  long,  contracted,  and  adherent  prepuce,'  to  enable  the  opening 
to  close.  Whenever  there  is  a  urethral  obstruction,  this  should 
be  remedied  as  a  preliminary  measure,  as  in  the  memorable  in- 
stance observed  by  Cabriol,^  Demonstrator  of  Anatomy  in  the 
Medical  School  at  Montpellier,  in  the  reign  of  Henry  IV.  The 
subject  was  a  girl,  eighteen  years  of  age,  who,  from  the  moment 
of  her  birth,  voided  her  urine  at  the  umbilicus,  which  was  four 
inches  in  length,  and  resembled  the  comb  of  a  turkey.  The 
obstruction  in  the  urethra  was  formed  by  a  thick,  firm  mem- 
brane, which  was  divided,  and  a  leaden  catheter  introduced  into 
the  bladder,  to  conduct  off  the  urine,  until  the  parts  should  be 
healed.  On  the  following  day,  Cabriol  cast  a  stout  ligature 
around  the  projecting  portion  of  the  navel,  which  he  then  cut 
oft"  close  to  the  seat  of  the  constriction,  the  operation  being  com- 
pleted by  the  application  of  the  actual  cautery. 

The  treatment  pursued  in  the  above  case  was  as  simple  as  it 
was  successful,  and  could  only  be  improved  by  omitting  the 
actual  cautery,  which  was  entirely  unnecessary. 

When  the  opening  is  seated  between  the  lips  of  the  umbilicus, 
the  edges  of  the  latter  should  be  freely  pared  and  approximated 
by  several  points  of  the  twisted  suture,  a  soft  catheter  being 
retained  in  the  bladder  to  take  oft'  the  pressure  of  the  urine.  A 
remarkable  case,  occurring  in  a  man  fifty-five  years  of  age,  was 
cured  in  this  way  b^'  Mr.  Thomas  Paget,^  of  Leicester,  England. 
The  opening  in  the  linea  alba  was  elliptical,  and  admitted  three 
fingers  in  its  long  axis,  which  was  horizontal,  and  two  in  its 
vertical.  Fifteen  years  previously,  Mr.  Paget'*  extracted  through 
the  open  urachus  a  ring-shaped  vesical  calculus,  which  had  formed 
on  a  hair,  and  he  removed  a  disk-shaped  stone  subsequently.  The 
malformation,  which  had  existed  from  birth,  was  associated  with 
an  umbilical  hernia  of  the  volume  of  a  goose's  egg,  which  was 
greatly  diminished  in  size  by  the  operation. 

'  Sec  case  of  Dr.  Charles,  of  Belfast,  British  Medical  Journal,  Oct.  10,  1875, 
p.  486. 

2  01)servat.  Anatomic,  Ob.  23. 

3  Med.-Chir.  Trans.,  vol.  xliv.  p.  13.  •»  Ibid.,  vol.  xxxiii.  p.  294. 


24 


PART    II. 
DISEASES  AND  INJURIES  OF  THE  PROSTATE  GLAND. 


CHAPTER    I. 

INFLAMMATION  OF  THE  PROSTATE  AND  ITS  RESULTS. 

Sect.  L— ACUTE  PROSTATITIS. 

Acute  inflammation  of  the  prostate  seldom  exists  as  a  primary 
afl:ection,  except  when  it  is  produced  by  direct  injmy.  In  gene- 
ral, it  is  altogether  of  a  secondary  character,  or  the  result  of  an 
extension  of  disease  from  the  adjacent  and  associated  organs. 
It  is  most  frequently  met  with  in  middle  life,  when  the  genital 
organs  are  in  their  full  vigor ;  while  it  is  comparatively  rare  in 
childhood  and  old  age,  when  these  organs  are  either  in  a  state 
of  latency,  or  ill  fitted  for  the  discjiarge  of  their  functions.  The 
disease,  as  in  other  parts  of  the  body,  may  be  idiopathic  or  trau- 
matic. 

The  most  common  existing  causes  of  acute  prostatitis  are  the 
extension,  by  continuity  of  structure,  of  inflammation  of  the 
mucous  membrane  of  the  urethra,  especially  the  gonorrhoeal, 
stricture  of  the  urethra,  or  other  impediment  to  the  free  flow  of 
the  urine,  suppression  of  the  cutaneous  perspiration,  cold  applica- 
tions to  the  perineum,  particularly  when  the  body  is  overheated, 
and  there  is  gonorrhoeal  discharge,  or  the  subject  is  gout}^  or 
rheumatic,  direct  injury,  the  rude  introduction  of  the  catheter, 
or  the  protracted  retention  of  that  instrument  in  the  bladder, 
the  passage  of  fragments  of  calculi,  and  irritating  applications 
made  to  the  prostatic  portion  of  the  urethra.  Venereal  excesses, 
onanism,  frequent  and  prolonged  erections,  and  constant  exercise 
upon  horseback,  will  also  occasionally  produce  the  disease,  by 
maintainino-  habitual  eno-oro-cment  of  the  o-land. 


372  INFLAMMATION    OF    THE    PROSTATE. 

The  initial  morbid  changes  met  with  in  this  aiFection  are 
hyperemia  and  tumefaction,  which  depend  mainly  upon  an  eftu- 
sion  of  serum  in  the  meshes  of  the  connective  tissue  of  the  gland, 
and  upon  a  dilated  condition  of  its  capillary  vessels.  In  the 
more  severe  forms,  there  is,  in  addition,  a  deposition  of  lymph, 
of  blood,  and  even  of  pus.  The  latter  fluid  generally  exists  in 
minute,  disseminated  points,  not  larger  than  a  pin's  head,  and 
of  a  pale  straw  color.  They  are  most  conspicuous  in  the  con- 
nective tissue  of  the  organ,  a  section  of  which,  when  thus  affected, 
beai-s  a  tolerabl3'  close  resemblance  to  the  pulmonary  tissues  in 
a  state  of  gray  hepatization. 

The  gland  is  red,  and  infiltrated,  and,  in  the  advanced  stages 
of  the  disease,  soft  and  friable.  The  mucous  follicles  are  en- 
larged, injected,  and  distended  with  a  thick,  ropy  secretion  ;  the 
excretory  ducts,  on  the  contrary,  are  generally  diminished  in 
size,  and  sometimes  even  obliterated  by  the  adhesion  of  their 
sides.  Occasionally  they  yield,  upon  pressure,  a  thin,  blood}-, 
and  slightly  viscid  fluid.  The  fibrous  capsule  is  unnaturally 
red  and  vascular,  tense,  and  covered,  here  and  there,  with  plastic 
deposits.  The  size  of  the  gland  varies,  in  different  cases,  from 
the  slightest  increase  of  the  natural  bulk  to  the  volume  of  a 
walnut,  a  hen's  egg,  or  an  orange.  The  swelling  generally  in- 
volves both  the  lateral  lobes,  although  not  in  an  equal  degree. 
The  body  and  middle  lobe  are  also  frequently  much  enlarged. 
The  parts  adjacent  to  the  prostate  usually  participate  in  the 
morbid  changes. 

An  attack  of  acute  prostatitis  is  sometimes  sudden  and  unex- 
pected ;  at  other  times  gradual,  and  preceded  by  symptoms  of 
general  indisposition.  From  whatever  cause  it  may  proceed,  the 
first  intimation,  in  general,  of  its  occurrence  is  pain,  with  burn- 
ing,and  a  sense  of  weight  at  the  neck  of  the  bladder,  soon  followed 
by  a  frequent  and  almost  irrepressible  desire  to  void  the  urine. 
The  pain  at  first  is  slight,  and  of  a  dull,  heavy,  aching  character; 
but,  as  the  malady  progresses,  it  rapidly  augments  in  severity, 
and  becomes  sharp,  darting,  pungent,  or  stinging ;  it  is  deep- 
seated,  more  or  less  constant,  and  is  increased  by  the  erect  pos- 
ture, by  any  sudden  concussive  movements  of  the  body,  by 
pressure  upon  the  perineum  and  hypogastrium,  by  defecation 
and  micturition,  and  by  pressure  of  .the  finger  in  the  rectum. 
The  pain  often  shoots  along  the  pubes,  thighs,  ureters,  and  sper- 


ACUTE    PROSTATITIS.  378 

mntic  cords ;  and  is  sometimes  exceedingly  distressing  even  in  the 
sacrolumbar  region.  In  the  more  violent  forms  of  the  complaint, 
and  especially  when  suppuration  is  threatened,  it  is  throbbing 
or  pulsatile.  The  testicles  are  retracted  towards  the  abdominal 
rings,  and  a  feeling  of  numbness  is  experienced  in  the  surround- 
ing parts.  The  difficulty  of  micturition,  which  is  usually  a 
prominent  feature,  even  in  the  early  stage  of  the  disease,  keeps 
steady  pace  with  the  swelling  of  the  prostate,  and  is  often  suc- 
ceeded by  complete  retention.  The  urine  is  generally  scanty, 
higli-colored,  dirty,  or  turbid,  and  so  acrid  as  to  occasion  severe 
scalding  or  burning  as  it  passes  along  the  urethra.  It  commonly 
contains  a  considerable  quantity  of  mucus,  the  product  both  of 
the  aft'ected  gland  and  of  the  urinary  bladder,  the  inner  mem- 
brane of  which  always  participates,  at  an  early  period,  in  the 
morbid  action.  In  some  instances,  especially  in  the  more  vio- 
lent forms  of  the  disease,  blood  follows  the  last  drops  of  urine. 

The  rectum  generally  becomes  involved,  from  extension  of 
the  original  disease,  at  an  early  stage  of  the  inflammation.  The 
patient  experiences  a  frequent  inclination  to  go  to  stool ;  the 
parts  are  exquisitely  tender  and  painful  ;  the  feces  are  voided 
with  much  difficult}-,  and,  not  infrequently,  in  a  flattened  or 
compressed  form;  and  there  is  a  constant  feeling  of  tenesmus. 
In  many  cases,  when  the  disease  has  existed  several  days,  the 
bowel  feels  as  if  it  were  stufled  or  filled  with  a  foreign  l)ody ; 
and,  if  the  finger  be  introduced  into  it,  the  inflamed  gland  will 
be  found  to  be  exquisitely  tender,  and  to  form  a  tumor  which 
is  so  large,  in  some  instances,  as  almost  to  obliterate  the  cavity 
of  the  tube.  If  an  attempt  be  made,  at  this  stage  of  the  com- 
plaint, to  pass  a  catheter,  the  instrument  will  be  likely  to 
become  arrested  by  the  enlarged  organ  and  to  cause  severe  pain 
and  spasm.  Priapism  sometimes  attends,  and  occasionally  there 
are  involuntary  discharges  of  semen,  generally  tinged  with 
blood. 

These  local  symptoms  are  commonly  accompanied  by  well- 
marked  constitutional  disturbance.  The  countenance  is  flushed ; 
the  skin  hot  and  dry;  the  pulse  full,  hard,  and  frequent;  the 
tongue  furred,  and  the  appetite  impaired.  The  thirst  is  com- 
monly urgent;  tliere  is  excessive  restlessness;  the  bowels  are 
constipated ;  and  not  infrequently  there  is  nausea  and  even 
vomiting.      Delirium  occasionally  exists,  and  generally,  espe- 


374  INFLAMMATION    OF    THE    PROSTATE. 

cially  when  attended  by  rigors,  denotes  the  approach  of  suppu- 
ration. 

Acute  prostatitis  is  liable  to  be  mistaken  for  other  affections. 
Cystitis  and  stone  in  the  bladder  are  the  diseases  with  which  it 
is  most  apt  to  be  confounded.  In  general,  however,  the  diag- 
nosis is  sufficiently  easy.  The  characteristic  symptoms  are  the 
deep-seated,  burning,  and  throbbing  pain  about  the  anus,  the 
gradually  increasing  frequency  in  micturition,  with  diminution 
of  the  size  of  the  stream,  and  pain  referred  to  the  head  of  tlie 
penis  at  the  completion  of  the  act,  the  excessive  scalding  of  the 
urethra,  the  feeling  of  weight  and  stuffing  in  the  rectum,  the 
constant  tenesmus  and  desire  to  go  to  stool,  and  the  flattened 
form  of  the  feces.  When  all  these  phenomena  are  present,  hardly 
a  reasonable  doubt  can  exist  in  respect  to  the  true  nature  of  the 
malady,  especially  if  it  have  supervened  suddenly  upon  external 
violence  or  the  suppression  of  a  gonorrhceal  discharge.  Fortu- 
nately, however,  the  surgeon  need  not  rely  upon  these  or  any 
other  symptoms  to  determine  the  diagnosis.  In  all  cases  he  has 
it  in  his  power  to  examine  the  gland  directly  with  the  iinger  and 
the  catheter.  "With  the  former  of  these  in  the  rectum,  the  pros- 
tate, as  before  stated,  can  be  distinctly  felt  as  a  solid,  painful 
tumor,  sometimes  almost  sufficiently  large  to  close  the  tube  and 
seriously  impede  the  passage  of  the  feces ;  whilst,  if  he  attempt 
to  introduce  the  latter  into  the  bladder,  he  will  lind  it  exceed- 
ingly difficult,  if  not  impracticable,  to  succeed,  unless  he  pos- 
sesses more  than  ordinary  skill  in  the  management  of  this 
instrument.  The  enlargement  upon  which  these  obstacles 
depend  is,  of  course,  always  more  conspicuous  after  the  inflam- 
mation has  made  some  progress ;  in  its  early  stages  it  is  fre- 
quently very  slight. 

In  cystitis  the  prostate  is  little,  if  at  all,  enlarged ;  there  is  less 
pain  and  tenderness  on  pressure  of  the  perineum  and  the  rectum  ; 
the  urine  is  retained  with  more  difficulty,  and  is  generally  voided 
every  few  minutes  ;  the  lower  bowel  sufl:ers  less,  and  the  patient 
does  not  experience  the  feeling  of  fulness  and  stuffing  about  the 
anus  that  he  does  in  inflammation  of  the  prostate.  In  stone  of 
the  bladder,  the  symptoms  are  usually  less  urgent  than  in  either 
of  the  other  affections,  and  all  doubt  about  the  case  generally 
vanishes  under  the  operation  of  sounding. 

Acute  prostatitis  is  generally  rapid  in  its  course.     It  seldom 


ACUTE    PROSTATITIS.  375 

continues  longer  than  eight  or  ten  days  witliout  tending  to  reso- 
lution or  suppuration.  When  the  attack  is  moderate,  or  even 
^vhen  it  is  violent,  provided  it  be  combated  by  prompt  and  effi- 
cient means,  it  usually  ends  favorably.  When  resolution  is 
about  to  take  place,  the  local  distress  gradually  diminishes, 
micturition  is  performed  with  more  facility,  the  urine  becomes 
more  abundant  and  assumes  a  lighter  color,  the  fever  subsides, 
and  the  skin  is  rendered  uniformly  soft  and  moist.  The  forma- 
tion of  matter  is  denoted  by  an  obstinate  persistence  of  the 
inflammatory  symptoms,  both  local  and  general,  by  rigors,  chills, 
or  shiverings,  by  violent  flushes,  by  a  heavy,  throbbing  pain  in 
the  affected  part,  by  delirium,  and,  not  infrequently,  by  reten- 
tion of  urine.  Idiopathic  prostatitis  never  terminates  in  gan- 
grene ;  but  this  effect  occasionally,  although  rarely,  follows  the 
traumatic  form  of  the  affection. 

Acute  prostatitis,  being  a  rapid  and  highly  dangerous  disease, 
must  be  met  with  the  most  energetic  antiphlogistic  measures. 
Free  depletion  by  the  lancet  or  by  leeches  to  the  perineum  and 
anus  is  almost  always  indicated,  and  should  be  practised  with 
the  least  possible  delay.  If  the  bowels  are  overloaded,  the  vene- 
section is  immediately  followed  by  an  active  purgative,  consisting 
of  an  ounce  of  sulphate  of  magnesia  with  the  eighth  of  a  grain 
of  tartar  emetic;  or,  if  there  be  decided  evidence  of  bilious 
derangement,  of  a  full  dose  of  calomel  and  jalap.  If  much  fever 
be  present,  accompanied  with  heat  and  dryness  of  the  skin,  thirst, 
restlessness,  and  high  arterial  action,  the  patient  may  at  once  be 
put  upon  the  use  of  the  antimonial  and  saline  mixture  in  union 
with  morphia  and  aconite,  or  veratrum  viride.  Or,  instead  of 
this  combination,  if  the  activity  of  the  pulse  has  been  moderated 
by  the  previous  treatment,  Dover's  powder,  or  a  solution  of 
acetate  of  ammonia,  may  be  given,  aided  by  tepid  demulcent 
drinks,  and  the  warm  bath.  The  kind  of  bath  is  an  object  of 
no  little  importance  in  the  management  of  this  disease.  The 
hip-bath  is  the  one  usually  recommended;  but  I  am  satisfied 
that  its  beneficial  effects  are  frequently  more  thau  counter- 
balanced by  the  inconveniences  which  attend  its  administration. 
All  the  good  effects  that  can  be  desired  in  such  cases  may  be 
readily  obtained  from  the  steam  bath,  prepared  either  by  con- 
ducting the  vapor  of  hot  water  to  the  body  of  the  patient  from 
a  teakettle,  or  by  placing  near  him,  under  the  bedclothes,  a  few 


376 


INFLAMMATION    OF    THE    PEOSTATE. 


hot  bricks,  wrapped  up  in  flannels  previously  moistened  -with 
vineijar  and  water.  13y  either  contrivance,  free  diajihoresis  may 
generally  be  induced  in  a  few  minutes.  The  perineum,  genital 
oro-ans,  and  hypogastrium  should  be  kept  constantly  covered 
with  flannel  cloths,  wrung  out  of  hot  water  and  laudanum ;  and 
the  pain  and  straining  should  be  promptly  subdued  by  the  hy- 
podermic use  of  morphia. 

The  condition  of  the  bladder  is  early  attended  to,  and  reten- 
tion of  urine,  so  liable  to  occur  during  the  progress  of  the  com- 
plaint, is  promptly  relieved  with  the  catheter,  a  soft,  bulbous, 
elastic  one  being  always  preferable  for  the  purpose.  As  the 
operation  is  generally  painful,  and  productive  of  spasmodic  con- 
traction of  the  parts  about  the  neck  of  the  bladder,  it  is  a  good 
plan  to  exhibit,  a  few  hours  before  it  is  attempted,  a  full  ano- 
dyne enema.  Absolute  rest  in  the  recumbent  posture  is  indis- 
pensable throughout  the  wliole  treatment ;  the  diet  must  be 
of  the  most  bland  and  simple  character ;  and  the  drinks  must 
consist  of  gum  water,  linseed  tea,  slippery  elm  water,  and  other 
mucilaginous  fluids  administered  in  small  quantities. 

Sect.  II.— ABSCESS  OF  THE  PROSTATE. 


Fig.  113. 


Acute  inflammation,  if  unsubdued,  occasionally  terminates  in 
abscess,  which  may  be  seated  in  any  part  of  the  prostate.     The 

middle  lobe,  however,  is  less  lia- 
ble to  sufier  than  the  rest  of  the 
organ,  and  often  escapes  entirely, 
even  when  the  latter  is  nearly 
destroyed  by  it.  Occasionally  it 
exists  simultaneously  at  all  these 
points.  In  the  annexed  cut,  fig. 
113,  from  a  specimen  in  my  private 
cabinet,  the  abscess  was  seated  in 
the  lateral  lobe. 

Abscesses  of  the  prostate  vary 
much  both  in  their  number  and  size.  Usually,  there  is  only 
one,  while  at  other  times  there  are  as  many  as  six  or  eight, 
twelve,  or  even  twenty,  scattered  through  the  substance  of  the 
organ,  and  giving  it,  when  their  contents  are  removed,  a  rid- 
dled, cribriform  appearance.     Under  such  circumstances  it  is 


ABSCESS    OF    THE    PROSTATE.  377 

not  uncommon  for  several  of  them  to  communicate  together. 
Wlicn  numerous,  their  dimensions  are  generally  proportionately 
small,  not  exceeding,  perhaps,  the  volume  of  a  millet-seed  or  a 
pea.  A  solitary  ahscess  of  large  size  is  sometimes  seen :  I  have 
evacuated  one  which  contained  eight  ounces  of  pus. 

When  the  abscess  is  of  long  standing,  or  slow  in  finding  an 
outlet,  it  is  generally,  no  matter  what  may  be  its  size,  surrounded 
by  a  cyst,  of  a  pale-yellowish  color,  dense  in  texture,  and  from 
the  fourth  of  a  line  to  a  line  in  thickness.  The  contents  of  such 
a  depot  do  not  differ  essentially  from  those  of  a  common  phleg- 
monous abscess  in  other  parts  of  the  bod3^  In  general,  they 
are  of  a  light  straw  color,  and  of  a  thick,  cream-like  consis- 
tence, free  from  odor,  and  possessed  of  all  the  properties  of 
laudable  pus.  Sometimes,  however,  they  are  more  or  less  bloody, 
or  serosanguinolent,  and  intermixed  with  lymph,  mucus,  and  the 
debris  of  the  affected  gland.  Occasionally,  especially  when  it  is 
long  retained,  the  matter  is  excessively  fetid. 

The  structures  around  the  abscess  are  infiltrated  witli  serous 
and  other  fluids,  more  or  less  softened,  and  of  a  brownish  or 
reddish  appearance,  from  the  injected  condition  of  their  capil- 
laries. When  the  purulent  collections  are  numerous,  they  are 
sometimes  entirely  disorganized,  and  converted  into  a  substance 
closely  resembling  wet  tow.  A  common  and  almost  a  necessary 
effect  of  an  abscess  of  the  prostate  is  the  formation  of  a  cavity, 
which  is  often  more  serious  in  its  consequences  than  the  abscess 
itself. 

Abscesses  of  the  prostate  open  in  different  directions,  as  the 
urethra  and  bladder,  the  rectum,  the  perineum,  and  the  perito- 
neal cavity.  The  most  natural,  although  at  the  same  time  the 
most  unfortunate  direction,  as  it  respects  the  affected  structures, 
in  which  the  collection  opens,  is  into  the  urinary  bladder,  or  the 
orifice  of  the  urethra,  from  which  the  matter  is  subsequently 
discharged  along  with  the  urine.  Sometimes  the  abscess  points 
and  breaks  simultaneously  at  both  these  situations.  When  it  is 
bulky,  a  large  quantity  of  pus  may  thus  be  evacuated  at  once  ; 
or  it  may  drain  off  slowly  and  almost  imperceptibly.  In  the 
former  case,  the  matter  may  be  discharged  in  a  pure  state,  or  it 
may  be  mixed  with  the  urine,  which  will  then  be  of  a  lactescent, 
whitish,  or  grayish  appearance,  and  perhaps  more  or  less  offen- 
sive ;  in  the  latter,  the  urine  will  exhibit  little,  if  any,  change, 


378  INFLAMMATION    OF    THE    PROSTATE. 

and  deposit  merely  a  thin,  whitish  sediment,  visible  at  the  bot- 
tom of  tlie  receiver.  Tlie  pus  may  be  evacuated  into  the  rectum, 
and  be  discharged  either  alone  or  in  union  with  the  feces.  This 
mode  of  communication  is  by  no  means  uncommon,  and  is  almost 
certain  to  occur  when  the  abscess  is  developed  in  the  posterior 
part  of  the  gland.  The  abnormal  opening,  situated  at  a  varia- 
ble height  from  the  anal  outlet,  is  generally  within  reach  of  the 
finger,  and  often  continues  fistulous  a  long  time,  permitting  a 
ready  interchange  of  the  contents  of  the  two  reservoirs.  The 
disease,  in  this  case,  is  frequently  complicated  with  inflamma- 
tion and  suppuration  of  the  seminal  vesicles  and  the  adjacent 
structures.  In  the  third  place,  the  pus  may  escape  externally 
by  inducing  ulceration  of  the  structures  of  the  perineum.  The 
progress  of  the  fluid  is  indicated  by  excessive  pain  in  the  part, 
and  by  a  hard,  red,  circumscribed  swelling,  which  finally  points, 
and  breaks.  In  some  instances  the  matter  escapes  into  the 
surrounding  connective  tissue,  and  extends  upwards  to  the 
scrotum  and  even  the  penis,  following  the  same  course  that  the 
urine  does  when  it  is  infiltrated  into  the  perineum.  Finally, 
the  abscess  may  burst  into  the  peritoneal  cavity,  at  the  side  or 
posterior  part  of  the  prostate,  and  so  cause  fatal  inflammation. 
The  occurrence,  which  is  fortunately  very  rare,  is  announced  by 
severe  pain  in  the  pelvic  region,  a  small,  quick,  and  contracted 
pulse,  violent  rigors,  and  rapid  prostration  of  the  vital  powers. 
Death  usually  occurs  in  from  thirty-six  to  forty-eight  hours. 

Such  are  the  various  points  at  which  the  matter  of  a  prostatic 
abscess  may  ultimately  find  an  outlet.  Of  these  the  first  is,  as 
previously  stated,  the  most  natural  as  well  as  the  most  frequent, 
but  also  at  the  same  time  the  most  undesirable  one,  as  it  involves 
a  greater  amount  of  risk  to  the  patient,  from  the  contact  of  the 
urine  with  the  cavity  of  the  purulent  depot  after  the  escape  of 
its  contents.  In  this  way  an  additional  cause  of  inflammation 
is  produced,  which  often  operates  to  the  destruction  both  of  the 
part  and  the  system.  The  passage  of  the  matter  across  the 
perineum  is  uncommon,  and  is  always  attended  with  great  delay 
and  immense  suffering,  on  account  of  the  resistance  ofl:ered  by 
the  fasciae  and  muscles  in  this  region.  The  escape  of  the  pus 
through  the  rectum  is  unfortunate,  as  it  frequently  entails  an 
obstinate  fistule ;  but  the  most  disastrous  route  of  all  is  that  in 


ABSCESS    OF    THE    PEOSTATE.  379 

which  the  contents  of  the  abscess  pass  into  the  peritoneal  cavity, 
and  excite  fatal  inflammation. 

This  disease  occurs  at  all  periods  of  life,  although  not  with 
equal  frequency.  Young  men  and  adults  are  most  prone  to  it; 
while  it  is  very  rare  in  childhood  and  old  age.  The  exciting 
causes  are  the  same  as  those  of  inflammation  of  the  prostate,  the 
most  frequent  being  such  as  occasion  obstruction  to  the  flow  of 
urine.  It  is  not  known  wdiat  influence,  if  any,  is  exerted  upon 
the  production  of  this  complaint  by  occupation,  season,  climate, 
and  other  circumstances.  It  is  supposed  that  senile  enlargement  of 
the  prostate  predisposes  to  its  occurrence.  That  this  view  is  not 
without  reason  is  shown  from  100  dissections  of  the  prostate 
after  the  sixtieth  year  by  Mr.  J.  C.  Messer,^  in  which  abscess 
was  met  with  5  times  in  35  cases  of  hypertrophy  of  this  organ, 
once  in  20  cases  of  atrophy,  and  once  in  45  cases  in  which  the 
gland  was  normal. 

The  formation  of  abscess  of  the  prostate  is  not  always  an- 
nounced by  characteristic  phenomena,  and  hence  it  not  infre- 
quently happens  that  the  first  intimation  wdiich  the  patient  and 
his  attendant  have  of  the  real  nature  of  the  case  is  a  sudden 
discharge  of  pus  along  the  urethra,  consequent  upon  the  intro- 
duction of  the  catheter,  or  a  violent  effort  at  micturition.  In 
general,  however,  when  this  event  is  about  to  take  place,  there 
is  an  increase  of  all  the  previous  symptoms,  both  local  and  con- 
stitutional. The  |iain  becomes  exceedingly  violent,  and  assumes 
an  aching,  throbbing  character ;  there  is  a  sense  of  weight  and 
pressure  at  the  neck  of  the  bladder  ;  the  patient  has  almost  a 
constant  desire  to  void  his  urine,  which  is  discharged  with  much 
difficulty,  and  either  in  drops,  or  in  a  small  and  feeble  stream ; 
the  urethra  is  the  seat  of  a  scalding  or  burning  sensation ;  the 
rectum  feels  as  if  it  w^ere  distended  by  a  foreign  body  ;  and  more 
or  less  uneasiness  is  experienced  in  all  the  associated  organs.  In 
some  instances  the  local  suffering  is  of  the  most  agonizing  de- 
scription, depriving  the  patient  of  appetite  and  sleep,  and  rapidly 
undermining  the  vital  powers.  Complete  retention  of  urine 
occasionally  supervenes.  Along  wdth  these  symptoms  there  are 
generally  severe  rigors,  alternating  with,  flushes  of  heat,  intense 
thirst,  excessive   restlessness,  high    fever,  and    even    delirium. 

'  London  Lancet,  May  19,  1860. 


380  INFLAMMATION    OF    THE    PROSTATE. 

AVheu  this  combination  of  phenomena  exists,  there  can  hardly 
he  any  doubt  about  the  nature  of  the  case,  especially  if  the 
individual  has  previously  labored  under  acute  or  chronic  prosta- 
titis. An  examination  by  the  rectum  will  afford  additional 
litcht,  and  will  often  detect  fluctuation,  more  particularly  if  the 
matter  occupies  the  posterior  part  of  the  gland.  At  an  advanced 
stasce  of  the  complaint,  the  abscess  may  point  in  the  bowel,  or  in 
the  perineum,  and  thus  remove  all  doul)t  respecting  the  diagnosis. 

Abscess  of  the  prostate  is  generally  to  be  regarded  as  a 
dangerous  affection.  The  local  suffering,  if  not  promptly  sub- 
dued by  a  natural  or  artificial  outlet  for  the  pent-up  fluid,  is  of 
itself  sufficient,  in  many  cases,  to  bring  on  serious,  if  not  fatal 
exhaustion.  Even  under  the  most  favorable  circumstances,  and 
where  there  is  apparently  little  danger  from  the  immediate 
ravages  of  the  malady,  the  patient  may  fall  a  victim  to  its 
secondary  efl'ects.  One  of  the  worst  consequences  of  this  affec- 
tion is  a  fistulous  communication  with  the  rectum,  the  urethra, 
the  perineum,  or  urinary  bladder,  which  it  is  sometimes  impossi- 
ble to  heal,  and  which  renders  the  individual  alike  uncomfortable 
to  himself,  and  disagreeable  to  those  around  him.  A  large 
abscess  is,  of  course,  all  other  circumstances  being  equal,  more 
dangerous  than  a  small  one,  and  a  number  of  small  ones  than  a 
solitary  small  one.  The  prognosis,  moreover,  will  be  materially 
influenced  by  the  patient's  habits,  his  age,  and  his  previous 
health. 

In  the  treatment  of  this  malady  the  leading  indications  are, 
to  limit  the  suppuration,  and  to  afford  as  speedy  an  outlet  as 
possible  to  the  effused  fluid.  To  fulfil  the  first,  prompt  recourse 
must  be  had  to  depletion,  provided  this  has  not  been  already 
carried  sufficiently  far,  to  antimonials,  diaphoretics,  anodynes, 
and  emollient  applications.  Leeches  to  the  perineum  and  the 
lower  part  of  the  hypogastrium  will  often  prove  eminently 
serviceable,  and  can  seldom  be  dispensed  with. 

The  second  indication  is  fulfilled  by  an  early  artificial  opening. 
If  the  abscess  points  towards  the  perineum,  a  long,  straight, 
narrow-pointed  bistoury  should  be  entered  in  the  raphe  about 
five  or  six  lines  above  the  anal  aperture,  and  thrust  directly 
onwards  in  the  direction  of  the  prostate,  which  is  supported  by 
the  finger  in  the  rectum.     The  incision  is  eularo-ed  towards  the 


ULCERATION    OF    THE    PROSTATE.  381 

scrotum,  on  withdrawing  the  knife,  and  its  edges  are  kept  apart 
by  a  small  tent,  to  prevent  premature  closure. 

When  the  collection  points  in  the  rectum,  as  will  he  indicated 
by  the  large  size  and  fluctuating  character  of  the  swelling,  it 
may  be  readily  reached  with  a  curved  trocar,  four  or  five  inches 
long.  The  patient  is  placed  as  in  the  operation  of  lithotomy, 
and  the  left  index  and  middle  fingers,  well  oiled,  are  carried  up 
the  bowel  until  they  come  in  contact  with  the  most  prominent 
part  of  the  abscess.  The  trocar,  concealed  within  its  canula,  is 
then  placed  in  the  groove  formed  by  the  junction  of  the  two 
fingers,  and  as  soon  as  it  has  reached  its  destination,  it  is  thrust 
into  the  swelling,  and  immediately  withdrawn,  at  the  same  time 
that  the  canula  is  pushed  farther  in.  When  the  matter  is  dis- 
charged, the  instrument  is  removed,  and  the  case  is  treated  upon 
general  principles.  For  some  days  after  the  operation,  the  lower 
bowel  should  be  kept  as  quiescent  as  possible. 

When  the  abscess  bulges  inwards  towards  the  urethra  and  the 
neck  of  the  bladder,  it  may  be  punctured  with  a  common  silver 
catheter ;  or,  instead  of  this,  a  sound  with  a  conical  beak  and  a 
small  curve  may  be  used.  The  slightest  pressure  frequently 
suffices  to  effect  the  object.  When  the  abscess  is  not  yet  com- 
pletely matured,  and  the  local  suffering  is  such  as  to  render  delay 
improper,  the  operation  may  be  executed  with  a  lanceted  stylet. 
When,  by  any  of  these  procedures,  the  matter  has  been  evacuated, 
the  urine  should  be  frequently  drawn  off  with  the  catheter,  to 
prevent  its  entrance  and  accumulation  in  the  interior  of  the  sac. 
For  this  purpose  the  catheter  of  Mercier,  represented  at  page 
114,  is  preferable,  as,  in  its  passage,  the  beak  hugs  the  roof  of  the 
urethra,  and  is  in  no  danger  of  entering  the  sac  of  the  abscess. 

Sect.  III.— ULCERATION  OF  THE  PROSTATE. 

Ulceration  of  the  prostate,  as  an  independent  affection,  is  of 
infrequent  occurrence,  and  of  difficult  recognition.  It  is  induced 
by  various  causes,  of  which  the  principal  are,  the  presence  of 
calculous  concretions  in  the  substance  of  the  organ,  wounds,  or 
lacerations,  whether  by  accident  or  the  forcible  employment  of 
instruments,  and  the  formation  and  evacuation  of  abscesses, 
Avhether  common  or  tubercular.  Of  these,  the  first  and  third 
are  doubtless  the  most  common. 


382  INFLAMMATION    OF    THE    PROSTATE. 

The  symptoms  which  accompany  ulceration  of  the  prostate 
are  such  as  indicate  the  existence  of  chronic  disease  of  this 
oro-an  and  of  the  neck  of  the  bladder.  The  patient  has  a  fre- 
quent desire  to  make  water,  the  passage  of  which  is  attended 
with  a  scalding  sensation  along  the  urethra,  and  more  or  less 
spasm  and  tenesmus ;  there  is  severe  pain  in  the  region  of  the 
affected  part,  of  a  sharp,  burning,  or  lancinating  cliaracter,  and 
darting  through  the  neighboring  parts  ;  constant  itcliing  and 
uneasiness  are  experienced  in  the  head  of  the  penis ;  and  the 
urine,  Avhich  is  voided  perhaps  every  half  hour,  is  more  or  less 
turbid,  and  loaded  with  a  thick,  glairy,  ropy  mucus.  Oceasion- 
alh'  there  is  a  discharge  of  blood,  variable  in  quantity,  as  well 
as  in  regard  to  the  frequency  of  its  recurrence.  The  local 
symptoms,  in  fact,  generally  strongly  simulate  those  of  vesical 
calculus.  The  introduction  of  the  catheter  is  always  attended 
with  excessive  pain,  and  an  aggravation  of  the  local  distress ; 
pressure  on  the  perineum,  and  the  insertion  of  the  finger  into 
the  rectum,  produce  similar  etfects.  In  the  more  violent  forms 
of  the  affection,  the  patient  finds  it  impossible  to  remain  long 
in  the  erect  posture,  or  even  to  sit  on  a  chair  ;  all  active  exercise, 
in  fact,  is  impracticable.  Perhaps  the  most  reliable  circum- 
stances, in  a  diagnostic  point  of  view,  are,  the  absence  of  vesical 
calculi,  long-continued  suflering  in  the  neck  of  the  bladder,  a 
constant  secretion  of  thick,  glairy  mucus,  a  frequent  desire  to 
void  the  urine,  and  an  occasional  discharge  of  blood.  In  the 
progress  of  the  disease,  the  constitution  necessarily  sutlers ;  the 
digestive  organs  become  deranged ;  the  fiesh  wastes ;  the  coun- 
tenance is  wan,  thin,  and  haggard  ;  the  pulse  is  small  and  irri- 
table ;  and  the  patient,  worn  out  by  the  loss  of  sleep  and  physical 
suffering,  gradually  falls  into  a  state  of  marasmus,  from  which 
be  is  destined  never  to  recover. 

The  treatment  of  ulceration  is  altogether  unsatisfactory  and 
empirical.  Attention  must  be  paid  to  the  general  health,  by 
regulating  the  diet,  the  bowels,  and  the  secretions ;  the  warm 
l)ath  should  be  used  from  time  to  time ;  the  patient  should  avoid 
exercise  and  the  erect  posture ;  pain  should  be  allayed  by  opiates; 
the  bladder  should  occasionally  be  washed  out  with  tepid  water, 
either  simple  or  medicated  ;  and  the  affected  surfaces  should  be 
lightly  touched  once  every  few  days  with  a  solution  of  nitrate 
of  silver,  ten  grains  to  the  ounce,  applied  with  a  piece  of  soft 


ULCERATION    OF    THE    PROSTATE.  383 

sponge,  projected  from  an  open  catheter  canula.  If  the  pain, 
scalding,  and  spasm  are  great,  leeches  and  counter-irritation  will 
be  beneficial.  The  best  internal  remedies  are  balsam  of  copaiba, 
ciibebs,  and  spirits  of  turpentine  largely  diluted  with  demulcent 
fluids.  When  no  impression  can  be  made  upon  the  sufi:ering 
parts  by  these  means,  the  only  rational  plan  is  to  divide  the 
gland  freely  through  the  perineum,  taking  care  to  keep  the 
wound  open  until  the  ulcers  are  healed. 


CHAPTER    II. 
PROSTATORRHCEA. 

Prostatorrhcea,  ail  aft'ectioii  which  I  have  been  the  first  to 
describe,'  is,  as  the  term  implies,  a  discharge  from  the  prostate 
gland,' generally  of  a  thin  mucous  character,  dependent  upon  sub- 
acute or  chronic  inflammation  of  the  glandular  elements  of  that 
organ,  and  liable  to  be  confounded  with  other  lesions,  as  gleet, 
seminal  losses,  and  cystorrhffia,  from  which,  however,  it  is  usually 
easily  distinguished. 

Prostatorrhcea  is  rare  in  childhood,  because  all  kinds  of  dis- 
eases of  the  prostate  are  uncommon  in  impabic  subjects.  That 
it  may  occur,  however,  even  at  a  very  tender  age,  is  altogether 
likely,  especially  in  children  laboring  under  stone  in  the  bladder, 
prolapse  of  the  bowel,  or  worms  in  the  rectum,  causing  reflected 
irritation.  After  the  twentieth  year  the  disease  is  sufficiently 
common,  and  instances  are  occasionally  met  with  even  in  very 
old  persons.  As  long  as  the  prostate  gland  remains  small  and 
inactive,  or  is  not  brought  fully  under  the  influence  of  the  sexual 
organs,  with  which  it  is  so  intimately  associated,  it  is  compara- 
tively infrequent. 

All  classes  of  persons  are  liable  to  sutler  from  this  affection ; 
but  it  is  most  frequent  in  those  of  a  sanguineo-nervous  tempe- 
rament, with  strong  sexual  propensities,  leading  to  frequent 
indulgence  of  the  venereal  appetite,  if  not  to  positive  venereal 
excesses,  either  in  the  natural  manner  or  by  masturbation.  An 
irritation  is  thus  established  in  the  prostate  gland,  attended 
with  more  or  less  discharge  of  its  peculiar  secretion,  normal  or 
abnormal.  Single  and  married  men  are,  apparently,  equally 
pi-one  to  it.  Once  established,  it  is  probable  that  certain  occu- 
pations may  serve  to  keep  it  up ;  and  it  is  also  likely  that  there 
are  certain  employments  which  may  predispose  to  it.  Intem- 
perance in  eating  and  drinking,  frequent  horseback  exercise, 

'  Xorth  Amer.  Med.-Chir.  Rev.,  July,  18G0,  p.  G93. 


PROSTATOREIKEA.  385 

sexual  abuse,  and  disease  of  the  bladder,  anus,  and  rectum,  may 
all  be  regarded  as  contributing  to  such  a  result. 

The  exciting  causes  of  prostatorrhoea  are  not  always  very 
evident.  In  most  cases  the  affection  is  traceable,  either  directly 
or  indirectly,  to  venereal  excesses,  unsatisfied  sexual  appetite, 
chronic  inflammation  of  the  neck  of  the  bladder,  stricture  of 
the  urethra,  especially  when  seated  far  back,  or  hypersesthesia 
of  this  canal.  Sometimes  it  has  its  origin  in  disorder  of  the 
lower  bowel,  as  hemorrhoids,  prolapse,  fissure,  fistule,  ascarides, 
or  the  lodgment  of  some  foreign  body.  It  is  easy  to  conceive 
how  reflected  irritation  might  induce  this  disease.  The  connec- 
tion between  the  prostate  gland  and  ano-rectal  region  is  very 
close  and  intimate,  and,  hence,  whatever  affects  the  one  will 
almost  be  sure,  in  time,  to  implicate  the  other,  either  in  conse- 
quence of  proximity  of  structure,  or  of  nervous  communication. 
Temporary  prostatorrhoea  is  occasionally  excited  by  the  exhibi- 
tion of  internal  remedies,  as  drastic  cathartics,  cantharides,  and 
spirits  of  turpentine  ;  or,  in  short,  whatever  has  a  tendency  to 
invite  a  preternatural  afflux  of  blood  to  the  prostate  gland  and 
neck  of  the  bladder,  or  to  the  posterior  portion  of  the  urethra. 
Another  cause  of  the  disease,  and,  according  to  my  experience, 
a  very  common  one,  especially  in  young  men,  is  masturbation  or 
self-pollution.  Many  of  the  most  obstinate  and  perplexing  cases 
of  it  that  have  come  under  my  notice  were  the  direct  result  of 
this  detestable  practice. 

The  symiitoms  of  prostatorrhoea  are  sufiSciently  characteristic. 
1'he  most  prominent,  as  already  stated,  is  a  discharge  of  mucus, 
generally  perfectly  clear  and  transparent,  more  or  less  ropy,  and 
of  varying  quantity,  from  a  few  drops  to  a  drachm  and  upwards, 
in  the  twenty-four  hours.  It  is  seldom  that  it  is  puriform,  and 
still  more  rare  that  it  is  purulent ;  but  it  frequently  contains 
mucopurulent  casts  of  the  ducts  of  the  prostatic  follicles,  which 
appear  like  bits  of  thread  floating  in  the  urine.  When  consid- 
erable, the  flow  keeps  up  almost  a  constant  moisture  at  the 
orifice  of  the  urethra,  and  may  even  make  a  decided  impression 
upon  the  patient's  linen,  leaving  it  wet  and  stained,  somewhat 
in  the  same  manner  as  in  gleet  or  gonorrhoea,  though  in  a  much 
less  marked  degree.  The  most  copious  evacuations  of  this  kind 
generally  occur  while  the  patient  is  at  the  water-closet,  engaged 
in  straining,  especially  if  the  bowels  are  constipated,  or  the  fecal 
25 


386  PROSTATORRHCEA. 

matter  is  uncommonly  hard,  or  greatly  distends  the  rectum,  so 
as  to  exert  an  unusual  amount  of  pressure  upon  the  prostate 
gland. 

The  discharge,  whether  small  or  large,  is  often  attended  with 
a  peculiar  tickling  sensation,  referred  by  the  patient  to  the  pros- 
tate gland,  from  which  it  frequently  extends  along  the  whole 
leno-th  of  the  urethra,  and  even  to  the  head  of  the  penis.  In 
some  cases,  indeed  in  many,  the  feeling  is  of  a  lascivious,  volup- 
tuous, or  pleasurable  nature,  not  unlike  that  which  accompanies 
the  earlier  stages  of  Sexual  intercourse.  Xot  a  few  patients 
experience  what  they  call  a  "  dropping  sensation,"  as  if  the  fluid 
fell  from  the  prostate  gland  into  the  urethra.  Other  anomalous 
symptoms  often  present  themselves,  such  as  a  feeling  of  weight 
and  fatigue  in  the  region  of  the  prostate,  the  anus  and  rectum, 
or  along  the  perineum,  with,  perhaps,  more  or  less  uneasiness  in 
voiding  urine,  and  a  frequent  desire  to  em[tty  the  bladder  ;  some 
patients  are  troubled  with  morbid  erections,  and  their  sleep  is 
interrupted  with  lascivious  dreams. 

It  is  astonishing  how  much  the  patient's  mind  often  suffers 
in  this  affection.  The  discharge,  even  if  ever  so  insignificant, 
occasions  him  the  greatest  possible  disquietude  ;  for  at  one  time 
he  imagines  that  it  is  a  source  of  much  bodily  debility,  or  that 
it  is  productive  of  weakness  and  soreness  in  the  dorsolumbar 
region,  especially  if  these  symptoms  happen  to  coexist ;  at  an- 
other, that  he  is  about  to  become  impotent,  under  the  delusive 
idea  that  the  flow  is  one  of  a  seminal  character ;  an  idea  which 
not  unfrequcntly  haunts  him  day  and  night,  and  from  which 
hardly  anything  can,  perhaps,  even  temporarily  divert  his  at- 
tention. His  mind,  in  short,  is  poisoned,  and  the  consequence 
is  that  he  is  incessantly  engaged  in  trying  to  obtain  relief,  run- 
ning from  one  practitioner  to  another,  distrusting  all,  and  aflord- 
ing  none  an  opportunity  of  doing  him  an}'  good.  In  the  worst 
forms  of  the  attection,  his  business  habits  are  destroyed,  he 
becomes  morose  and  dyspeptic,  and  he  literally  spends  his  time 
in  watching  for  the  discharge  which  is  the  source  and  cause  of 
his  terrible  suffering. 

The  aftections  with  which  prostatorrhrea  may  be  confounded 
are  the  various  forms  of  urethritis,  especially  gleet,  discharges 
of  semen,  and  chronic  inflammation  of  the  bladder. 

From  urethritis,  whether  common  or  specific,  it  is  generally 


PROSTATORRHCEA.  387 

easily  distinguished  by  the  history  of  the  case,  the  nature  of  the 
discharge,  and  the  attendant  local  phenomena.  In  most  cases, 
the  aft'ection  comes  on  gradually,  not  suddenly,  as  in  gonorrhoea 
or  simple  inflammation,  and  without  impure  connection ;  the 
discharge  is  white  or  grayish,  translucent,  and  ropy,  not  puru- 
lent, opaque,  and  yellowish ;  and  there  is  ordinarily  no  burning 
or  scalding  in  micturition.  In  gleet,  the  signs  of  distinction 
are  sometimes  more  diflicult ;  but  even  here  a  satifactory  con- 
clusion may  generally  be  reached  by  a  careful  consideration  of 
the  history  of  the  case,  and  a  proper  examination  of  the  dis- 
charge, which  is  nearly  always  more  or  less  puriform,  as  well  as 
more  abundant  than  in  prostatorrhoea.  When  the  discharge  of 
the  urethra  is  kept  up  by  the  presence  of  a  stricture,  the  diag- 
nosis can  be  determined  only  by  a  thorough  examination  with 
the  exploratory  bougie. 

Very  many  patients  confound  this  discharge  with  a  flow  of 
semen ;  an  idea  in  which  they  are  often  encouraged  by  their 
attendants,  in  consequence  of  their  ignorance  of  the  nature  of 
the  aliection.  Much  has  been  said  and  written  respecting  diur- 
nal spermatic  emissions ;  but,  according  to  my  experience,  these 
evacuations  are  among  the  rarest  occurrences  met  with  in  prac- 
tice. We  are  often  told  that  they  take  place  at  the  water-closet, 
during  eflbrts  at  straining,  and  this  is,  no  doubt,  occasionally 
the  case ;  but  more  commonly  it  will  be  found  that  these  dis- 
charges are  of  a  strictly  prostatic  character,  the  fluid  being 
forced  out  of  its  appropriate  rece[»tacles  into  the  urethra,  along 
which  it  is  presently  discharged.  This  delusion  will  be  more 
likely  to  take  hold  of  the  mind  it  the  escape  of  the  fluid  be 
accompanied  by  a  sort  of  pleasurable  sensation,  somewhat  simi- 
lar to  that  which  follows  a  feeble  emission.  Persons  aftected 
with  prostatorrhoea  will  often  tell  us  that  they  have  quite  a 
number  of  such  evacuations — perhaps  as  many  as  six  or  eight — 
during  the  twenty-four  hours,  especially  if  they  are  troubled 
with  disease  of  the  ano-rectal  region,  leading  to  frequent  visits 
to  the  water-closet,  or  if  they  are  much  in  female  society,  en- 
gaged in  exciting  reading,  or  addicted  to  the  pleasures  of  the 
table  or  to  inordinate  sexual  intercourse,  eventuating  in  general 
and  local  debility.  Should  the  historj^  of  the  case  fail  to  aftbrd 
the  requisite  light,  it  may  be  promptly  supplied  by  a  micro- 
scopic examination  of  the  suspected  fluid,  semen  always  reveal- 


3S8  PROSTATORRHCEA. 

ing  distinct  spermatozoa,  whereas  the  prostatic  and  urethral 
secretions  rarely  attbrd  any  such  indications.  The  prostatic 
mucus,  moreover,  diflcrs  from  that  poured  out  by  the  urethra  in 
containing  minute  concentric  amyloid  bodies. 

The  characteristic  symptom  of  cystorrhoea,  or  chronic  inflam- 
mation of  the  bladder,  is  an  inordinate  secretion  of  purulent 
mucus,  associated,  in  nearh'  all  cases,  with  an  altered  condition 
of  the  urine,  frequent  and  diflicult  micturition,  pain  in  the  region 
of  the  aifected  organ,  as  well  as  in  the  surrounding  parts,  and 
more  or  less  constitutional  disturbance.  In  prostatorrhoea  there 
may  also  be  more  or  less  uneasiness  low  down  in  the  pelvis,  with 
trouble  in  voiding  urine,  especially  where  the  prostate  is  much 
enlarged,  so  as  to  cause  constant  vesical  irritation  ;  but  the  two 
disorders  are  so  widelj'  dift'erent  as  to  render  it  impossible  to 
confound  them. 

The  pathology  of  tliis  ailection  consists  in  chronic  catarrhal 
inflammation  of  the  mucous  follicles  of  the  prostate,  leading  to 
an  inordinate  secretion  and  discharge  of  its  peculiar  fluid.  That 
this  is  the  case,  is  shown  by  the  character  of  tbe  concomitant 
phenomena,  and  also  by  the  fact  that  this  organ  is  frequently, 
if  indeed  not  general!}',  found  to  be  more  or  less  enlarged  and 
indurated,  and  painful  on  instrumental  contact.  ISTevertheless, 
there  are  cases,  and  these  are  by  no  means  uncommon,  in  which 
it  is,  to  all  appearance,  either  entirely  healthy,  or  so  nearly  so  as 
to  render  it  impracticable,  by  the  most  careful  exploration,  to 
discover  any  departure  from  the  normal  standard.  The  dis- 
charge under  such  circumstances  seems  to  be  the  result  solely  of 
a  heightened  functional  activity,  probably  connected  with,  if 
not  directly  dependent  upon,  disorder  of  the  seminal  vesicles, 
the  urethra,  neck  of  the  bladder,  or  recto-anal  structures ;  in 
other  words,  upon  reflected  irritation. 

The  prognosis  of  prostatorrhuea  is  generally  favorable ;  for  it 
does  not,  in  itself,  present  anj-thing  grave,  being,  as  just  stated, 
not  a  disease,  but  merely  a  symptom  of  a  disease,  usually  slight, 
and  therefore  easily  removable.  Its  obstinacy,  however,  is  often 
very  great,  and  hence  the  surgeon  should  always  be  guarded  in 
the  expression  of  his  opinion  respecting  a  rapid  cure.  When 
the  mind  deeply  sympathizes  with  the  local  atfection,  as  is  so 
frequently  the  case,  especially  in  young  men  of  a  nervous,  irrita- 


PROSTATORRHCEA.  389 

ble  temperament,  there  is  no  disease  which,  according  to  n)y 
experience,  is  more  difficult  of  management,  or  more  likely  to 
result  in  vexation  and  disappointment. 

In  the  treatment  of  this  aftection,  one  of  the  first  and  most 
important  objects  is  to  inquire  into  the  nature  of  the  exciting 
cause,  which  is  best  fulfilled  by  a  thorough  exploration  of  the 
genito-urinary  apparatus  and  of  the  anus  and  rectum.  For  this 
purpose,  a  catheter  or  exploratory  bougie  is  employed,  with  a 
view  of  ascertaining  the  condition  of  the  urethra,  the  prostate, 
and  the  bladder,  aided  by  the  finger  in  the  bowel,  previously 
emptied  by  an  enema.  In  this  manner,  the  surgeon  becomes  at 
once  apprised  of  the  existence  or  non-existence  of  stricture  of 
the  urethra,  and  of  the  presence  or  absence  of  morbid  sensibility 
of  its  mucous  membrane ;  the  size  and  consistence  of  the  pros- 
tate, and  the  state  of  the  urinary  reservoir,  particularly  as  to 
whether  there  is  inflammation,  stone,  hypertrophy,  or  other 
lesion.  The  finger  in  the  rectum  will  be  of  great  service,  not 
only  in  detecting  disease  in  the  prostate  and  bladder,  but  also 
in  this  tube  itself  and  in  the  anus.  Indeed,  without  its  aid  no 
exploration  of  these  organs  could  be  at  all  satisfactor3%  If  dis- 
ease of  the  seminal  vesicles  exist,  it  will  usually  be  evinced  by 
tenderness  on  pressure  through  the  wall  of  the  bowel,  provided 
the  finger  is  sufficiently  long  or  the  prostate  is  not  too  volumin- 
ous. 

The  habits  of  the  patient  should  be  particularly  inquired  into. 
In  mau}^  of  this  class  of  persons  they  are  decidedly  lascivious, 
or  marked  by  excessive  sexual  indulgence,  either  naturally  or 
in  the  form  of  masturbation,  the  prostate  gland,  seminal  vesicles, 
and  adjoining  structures  being  thus  kept  in  a  state  of  continual 
excitement,  highly  favorable  to  the  production  of  prostatorrhoea. 
The  nature  of  the  patient's  diet,  his  temperament,  the  state  of 
his  health,  and  his  mode  of  life  as  it  regards  sleep  and  exercise, 
both  of  mind  and  body,  also  deserve  special  consideration. 

Having  ascertained  the  above  facts,  or,  in  other  words,  having 
made  himself  perfectly  familiar  with  the  local  and  general  con- 
dition of  the  patient,  the  surgeon  will  be  able,  in  most  cases,  to 
institute  something  like  a  rational  mode  of  treatment.  This 
should  be  directed,  as  a  general  rule,  partly  to  the  system  at 
large,  partly  to  the  sufi'ering  structures. 

In  many  of  the  cases  the  patient  is  weak,  or  deficient  in  mus- 


390  PROSTATORRHCEA. 

cular  and  di2:estive  power,  indicating;  a  necessity  for  tonics,  as 
iron,  quinine,  and  stryclmia,  a  nutritions  diet,  with  a  glass  of 
sjenerous  wine,  and  gentle  exercise  in  the  open  air,  either  on 
foot  or  in  an  easy  carriage ;  riding  on  horseback  being  scrupu- 
lously avoided,  as  likely  to  keep  up  undue  excitement  in  the 
parts.  One  of  the  best  preparations  of  iron  is  the  tincture  of 
the  chloride,  in  union  with  tincture  of  nux  vomica,  in  the  pro- 
portion of  twenty  drops  of  the  former  to  ten  of  the  latter,  four 
times  a  day.  If  the  patient  be  plethoric,  he  may  use  with  great 
advantage  small  doses  of  tartar  emetic,  in  the  form  of  the  anti- 
monial  and  saline  mixture,  care  being  taken  not  to  nauseate. 
In  either  case,  it  is  of  paramount  importance  to  correct  the 
secretions  and  to  maintain  a  soluble  condition  of  the  bowels. 
Drastic  puro;atives  are  of  course  avoided,  as  they  would  onl}' 
tend  to  perpetuate  the  mischief.  Unless  the  patient  is  actually 
debilitated,  he  should  rigorously  abstain  from  condiments  and 
hi ffh- seasoned  dishes.  When  the  mucous  membrane  of  the  pros- 
tatic urethra  is  morbidly  sensitive,  bromide  of  potassium,  in  full 
doses,  is  indicated. 

Among  the  more  important  to})ical  remedies  are,  first,  moderate 
sexual  indulgence,  as  a  means  of  allaying  undue  excitement  of 
the  prostate  and  its  associated  organs ;  secondly,  cooling  and 
anodyne  injections,  or  weak  solutions  of  nitrate  of  silver  and 
laudanum,  or,  what  I  generally  prefer,  Goulard's  extract  with 
wine  of  opium,  in  the  proportion  of  from  one  to  two  drachms 
of  each  to  ten  ounces  of  water,  applied  by  means  of  the  catheter 
syringe  represented  at  page  78,  three  times  a  day,  and  retained 
three  or  four  minutes  in  the  passage.  In  obstinate  cases,  cauter- 
ization of  the  prostatic  portion  of  the  urethra,  or  even  of  the 
entire  length  of  this  canal,  may  be  necessary,  the  operation  being 
repeated  once  a  week.  When  the  prostatic  portion  of  the  ure- 
thra is  not  excessively  sensitive,  I  know  of  nothing  that  exerts 
so  beneficial  an  effect  as  the  introduction,  in  gradually  increas- 
ing sizes,  of  the  conical  steel  bougie,  at  first  every  second  day, 
and  afterwards  every  day.  The  cold  hip-bath  should  be  used 
twice  in  the  twenty-four  hours  ;  the  lower  bowel  should  be  kept 
cool  and  empty ;  and,  if  the  disease  do  not  gradually  yield, 
flying  blisters,  by  means  of  cantharidal  collodion,  should  be 
applied  to  the  perineum,  between  the  anus  and  scrotum. 

Whatever  may  be  the  plan  of  treatment,  perseverance  and  an 


PROSTATORRHCEA.  S91 

occasional  change  of  prescription  are  indispensable  to  success. 
When  there  is  deep  mental  involvement,  amounting  to  sexual 
hypochondriasis,  hardly  anything  will  effect  a  cure ;  or,  more 
correctly  speaking,  it  is  almost  impossible  to  induce  the  patient 
to  believe  that  he  is  well,  or  that  nothing  serious  is  the  matter 
with  him.  Under  such  circumstances  the  chief  dependence  must 
be  upon  travelling,  and  an  entire  change  of  scene  and  occupation. 
If  the  patient  be  single,  matrimony  should  be  enjoined. 


CHAPTER  III. 

HYPERTROPHY  OF  THE  PROSTATE. 

Hypertrophy  of  the  prostate  is  an  augmentation  of  the  volume 
of  that  oro:an,  produced  hy  increased  nutrition  and  excessive 
o;rowth  of  its  constituent  elements.  There  are  several  forms  of 
it,  but  the  most  common  hy  far  is  that  to  which  the  term  senile 
has  been  applied,  from  its  being  a  frequent  accompaniment  of 
old  age. 

Hypertrophy  may  occur  in  an}^  part  of  the  organ.  Most 
commonly  it  affects  the  entire  gland,  although  not  uniformly.  In 
about  15  per  cent,  of  all  instances,  enlargement  of  the  middle 
lobe  predominates ;  in  about  9  per  cent,  the  left  lateral  lobe,  and 
in  about  6  per  cent,  the  right  lateral  lobe,  is  mainly  aflected.  It 
rarely  happens  that  one  lobe  alone  is  the  seat  of  the  trouble. 

The  affection  exists  in  various  degrees,  from  the  slightest 
augmentation  of  the  natural  volume  of  the  prostate  to  the 
dimensions  of  a  pullet's  egg,  a  walnut,  an  orange,  or  even  a 
small  cocoanut.  The  greatest  increase  of  volume  usually  occurs 
in  the  long  axis  of  the  organ,  in  consequence,  no  doubt,  of  the 
want  of  resistance  in  this  direction.  Under  these  circumstances, 
the  lateral  lobes  are  of  an  elongated,  oval  shape,  generally  larger 
in  the  middle  than  at  the  extremities,  convex  in  front,  and 
rather  compressed  behind.  When,  on  the  contrary,  the  hyper- 
trophy advances  equally  in  all  directions,  these  bodies  will  be 
apt  to  be  somewhat  obround,  or  like  the  half  of  an  orange. 
Enlargement  of  the  gland  in  front  and  below  is  opposed  by  the 
elevator  muscles  of  the  anus,  the  deep  perineal  fascia,  and  the 
pubic  bones.  Occasionally  the  organ  increases  more  in  the 
transverse  than  in  the  vertical  diameter,  extending  outwards 
towards  the  sides  of  the  pelvis,  and  thus  overlapping  and  com- 
pressing the  rectum.  The  adjoining  engraving,  fig.  114,  from  a 
specimen  in  the  collection  of  Dr.  Sabine,  of  New  York,  represents 
the  prostate  greatly  enlarged  in  every  direction,  and  of  a  flattened, 
cylindrical  shape.     The  size  is  reduced  one-half. 


HYPERTROPHY    OF    THE    PROSTATE. 


393 


When  the  lateral  masses  are  equally  enlarged,  they  frequently 
project  inwards  towards  the  median  line,  so  as  almost  to  touch 
each  other.  This  occurrence,  however,  is  rare,  and  is  met  with 
only   in  the  more  aggravated    forms  of    the    malady.      More 


Fier.  114. 


General  Hypertiopliy  of  tlie  Prostate 

commonly  there  is  a  small  interval  between  them,  representing 
the  appearance,  when  the  gland  is  laid  open  longitudinally  along 
its  upper  surface,  of  a  median  groove  or  gutter.  When  one 
lateral  lohe  is  more  enlarged  than  the  other,  the  more  bulky  one 
frequently  encroaches  more  or  less  upon  the  smaller  one,  and  thus 
produces  a  lateral  curvature,  or  a  change  in  the  direction  of  the 
neck  of  the  bladder  and  the  commencement  of  the  urethra. 
Again,  it  occasi(raally  happens  that  one  lobe  projects  over  on 
one  side,  and  the  other  lobe  on  the  opposite,  giving  rise  thereby 
to  two  curvatures  instead  of  one,  as  in  the  former  case. 

Whatever  may  be  the  shape  of  the  enlarged  masses,  or  the 
direction  in  which  the  hypertrophy  occurs,  their  surfaces,  both 
external  and  internal,  may  be  perfectly  smooth,  or  they  may  be 
more  or  less  irregular,  bosselated,  and  even  lobulated.  Some- 
times small  prominences  exist  upon  tliem,  attached  by  a  broad 
base,  and  evidently  prolonged  from  their  substance,  which  thej^ 
resemble  in  color  and  structure.  Fig.  115,  from  a  specimen  in 
my  collection,  exhibits  this  form  of  the  enlargement.  Several 
such  bodies  are  occasionally  found  close  together,  thus  producing 
a  lobulated  appearance.  Cysts  sometimes  form  in  the  enlarged 
masses,  from  the  size  of  a  pea  up  to  that  of  a  large  marble,  tilled 


394 


HYPERTROPHY    OF    THE    PROSTATE. 


with  serous  fluid,  and  lined  by  a  fibrous  membrane.  Finally, 
the  surface  of  these  bodies  has  been  found  excoriated,  ilssured, 
and  even  ulcerated. 


Fiff.  115. 


Generil  Hypertropliy  of  tbe  Piostate. 


When  the  middle  lobe  is  hypertrophied,  it  generallj^  forms  a 
sort  of  mammillated  process,  which  is  more  or  less  vertical  in  its 


Fig.  116. 


Fio;.  117. 


Hypertrophy  of  the  Middle  Lobe. 


HYPERTROPHY    OF    THE    PROSTATE. 


395 


position,  and  varies  in  size  from  that  of  the  female  nipple  to  that 
of  a  pullet's  egg,  as  in  figs,  116'  and  117.  The  apex  of  the  tumor 
is  free  and  rounded,  while  the  base  is  immovably  fixed,  and  rests 
as  it  were  upon  the  posterior  extremity  of  each  lateral  mass.  Its 
position  is  usually  median ;  but  it  sometimes  projects  more  to 
one  side  than  the  other,  and  thus  creates  an  additional  impedi- 
ment to  the  introduction  of  the  catheter.  Although  the  form 
of  the  third  lobe,  when  hypertrophied,  is  generally  as  here  repre- 
sented, cases  occasionally  occur  in  which  it  is  exceedingly 
irregular,  setting  everything  like  accuracy  of  description  at 
defiance.  Next  to  the  mammillated  variety  is,  according  to  my 
own  observation,  the  triangular,  in  which  the  tumor  is  large 
behind  and  narrow  in  front,  terminating  in  a  tolerably  sharp 
crest.  More  rarely  it  is  of  a  rounded  shape,  or  broad  and  convex 
on  its  free  surface,  and  adherent  by  a  small  pedicle.  I  have  seen 
specimens  in  which  the  swelling  consisted  of  three  oblong  bodies. 


Fig.  118. 


^^.    jy^: 


m- 


Hypertrophy  of  all  the  Lobes. 


placed  side  by  side,  as  in  fig.  118,  from  a  specimen  in  nw  private 
cabinet ;  and  examples  are  recorded  in  wdiich  there  were  as  many 
as  four  and  even  five  such  lobes.  AVhatever  be  the  form  and 
volume  of  the  tumor,  it  always  projects  towards  the  bladder, 


•  From  a  specimen  in  the  private  collection  of  the  late  Professor  Mott. 


396  HYPERTROPHY    OF    THE    PROSTATE. 

(Irawino;  up  the  prostatic  portion  of  the  urethra,  and  elongating 
the  verumontanum. 

The  consistence  of  a  hypertrophied  prostate  is  liable  to  con- 
sidorahle  diversity,  and  occurs  under  two  very  opposite  forms, 
the  hard  and  the  soft.  In  the  first,  the  more  frequent  of  the  two, 
tlie  induration  varies  from  the  slightest  increase  of  the  natural 
consistence  to  the  firmness  of  the  fibrous  tissue.  When  the 
induration  exists  in  a  high  degree,  the  afifected  part  tears  with 
difllculty,  and  offers  considerable  resistance  to  the  scal[>el,  but 
does  not  yield  a  crepitating  sound.  Interspersed  through  its 
substance  are  numerous  enlarged  follicles  of  a  grayish  color, 
rounded  or  oval  in  their  shape,  and  hardly  as  large  as  a  millet- 
seed.  In  the  soft  variety,  the  enlargement  jiroceeds  in  a  more 
uniform  manner,  and  attains,  as  a  general  rule,  a  greater  magni- 
tude than  in  the  hard.  The  afiected  tissues  are  more  or  less 
elastic,  and  yield  readily  under  the  pressure  of  the  finger.  The 
follicles,  larger  and  more  conspicuous  than  in  the  first  variety, 
are  of  a  soft,  spongy  texture,  and  of  a  whitish  or  grayish  aspect. 

In  senile  hypertrojth}',  which  generally  takes  place  under  the 
infiuence  of  causes  operating  in  a  slow  and  gradual  manner, 
there  is  usually  a  diminution  of  color,  in  consequence,  apparently, 
of  the  concomitant  compression  of  the  capillary  vessels  which 
ramify  through  the  substance  of  the  organ.  Hence,  if  a  section 
be  made  of  the  parenchymatous  structure,  the  surface  will  be 
seen  to  be  of  a  dull  grayish,  ligbt  ash,  or  pale  drab  tint,  and  to 
emit  hardly  any  blood  on  pressure.  When  the  hypertrophy  is 
jiroduced  and  kept  up  by  irritation,  there  is  sometimes  an  increase 
of  color,  and  an  augmented  capillary  circulation.  Under  such 
circumstances,  the  parenchymatous  substance  may  exhibit 
various  shades  of  red  and  brown,  and  aftbrd  a  considerable 
quantity  of  blood  under  pressure  and  maceration. 

The  weight  of  a  liypertrophied  prostate  is  necessaril}'  aug- 
mented in  all  cases.  In  the  adult,  the  average  weight,  in  health, 
is  from  three  to  five  drachms.  In  the  afifection  under  considera- 
tion the  weight  ranges  from  seven  to  fourteen  drachms.  In  the 
more  aggravated  forms,  it  sometimes  amounts  to  several  ounces. 
Cadge*  met  with  an  instance  in  which  the  organ  weighed  twenty 
ounces,  and  measured  five  inches  in  length,  four  inches  in  width, 
and  three  inches  and  a  half  in  depth. 

'  Trans.  Path.  Soc,  Loiul.,  vol.  xviii.  p.  1S2. 


HYPERTROPHY    OF    THE    PROSTATE. 


397 


Hypertrophy  is  always  produced  by  causes  whicli  act  in  a 
slow  and  permanent  manner.  Habitual  engorgement  may, 
therefore,  be  regarded  as  its  immediate  precursor,  since  aug- 
mented action  necessarily  occasions  an  augmented  afflux  of  blood, 
and  a  corresponding  increase  of  nutrition.  Amongst  the  more 
frequently  enumerated  causes  are  prolonged  and  excessive  venery, 
stricture  of  the  urethra,  calculous  and'other  disease  of  the  blad- 
der, gonorrhoea,  and  horseback  exercise.  The  use  of  stimulating 
diuretics,  and  alcoholic  drinks,  exposure  to  cold,  the  repulsion 
of  cutaneous  diseases,  gout  and  rheumatism,  external  violence, 
the  frequent  introduction  of  the  catheter,  and  habitual  straining 
at  stool,  may  all  be  mentioned  as  so  many  exciting  or  predispos- 
ing causes  of  the  affection. 

H3q:)ertrophy,  not  the  result  of  old  age,  may  arise  at  any  period 
of  life,  under  the  influence  of  inflammatory  excitement  and  vascu- 
lar eno-oro-ement.  I  have  observed  cases  of  it  from  this  cause  in 
subjects  under  five  years  of  age,  but  it  is  most  common  in  middle 
life  from  the  extension  of  goiiorrhceal  inflammation  and  other 
sources  of  permanent  irritation. 

The  senile  form  of  the  affection  rarely  occurs,  at  least  not  in 
any  considerable  degree,  before  the  fiftieth  year  ;  slight  evidences 
of  it  are  occasionally  met  with  at  forty-five,  and,  indeed,  even  at 
forty,  but  this  is  exceedingly  rare.  It  was,  until  lately,  a  very 
generally  received  opinion  that  the  prostate  necessarily  enlarges 
in  elderly  subjects,  or,  in  other  words,  that  hypertrophy  is  a 
natural  result  of  old  age.  That  the  influence  of  advancing 
years,  however,  in  the  production  of  the  affection  has  been 
greatly  overrated,  will  appear  from  the  subjoined  table  of  312 
examinations  made  at  my  request  by  my  friend  Dr.  John  W. 
Lodge,  in  1859,  while  resident  physician  at  the  Philadelphia 
Hospital. 


Number. 

Age. 

Normal. 

Hypertrophied. 

Atrophied. 

23 

40  to     50 

21 

3 

,  , 

94 

50  to     60 

73 

18 

3 

113 

60  to     70 

84 

27 

3 

64 

70  to     80 

53 

11 

15 

80  to    90 

13 

3 

3 

90  to  100 

3 

•• 

To 

al  . . .  313 

246 

61 

5 

398  HYPERTROPHY    OF    THE    PROSTATE. 

It  thus  appears  tliat  hypcrtroph}-  of  the  prostate  occurred  in 
only  20  per  cent,  of  individuals  after  the  fiftieth  year,  a  result 
which  is  one-fifth  higher  than  that  obtained  by  Professor  Dittel 
and  Dr.  Chrostina'  from  an  examination  of  115  inmates  of  the 
Vienna  Almshouse,  whose  ages  varied  from  fifty-two  to  one 
hundred  years ;  the  average  being  seventy.  The  organ  was 
hypertrophied  in  18,  or  15  per  cent.,  and  atrophied  in  36,  or  31 
per  cent.  Of  164  dissections  of  the  prostate,  after  the  age  of 
sixty,  by  Sir  Henry  Thompson  and  Dr.  J.  C.  Messer,^  the  gland 
was  enlarged  in  56,  or  34  per  cent.,  and  atrophied  in  11,  or  6.7 
per  cent.  Hence  of  568  ante  or  post-mortem  examinations  of 
men  after  the  fiftieth  year,  only  133,  or  23.41  per  cent.,  disclosed 
the  existence  of  this  condition. 

It  is  interesting  to  observe  that,  while  hypertrophy  of  the 
prostate  is  most  common  between  fifty-five  and  sixty-five,  it 
does  not  appear  to  aftect  the  longevity  of  the  patient ;  nor  does 
it  awaken  any  symptoms  in  more  than  one-half  of  the  cases, 
or,  if  it  does,  it  is  not  a  subject  of  complaint.  Elderly  persons, 
however,  are  not  very  liable  to  call  attention  to  their  troubles, 
as  is  shown  by  some  facts  ascertained  by  Dr.  Lodge.  In  the 
majority  of  cases,  the  rectum  was  the  seat  of  hemorrhoids,  fistule, 
or  stricture,  innocent  or  malignant,  but  the  persons  were  not 
aware  of  their  existence. 

In  its  histological  construction,  an  hypertrophied  prostate 
may  be  regarded  as  a  tibromuscular  tumor,  as  it  depends  essen- 
tiall}-  upon  In-perplasia  of  the  muscular  and  fibrous  elements, 
which  constitute  its  parenchyma,  at  the  expense  of  the  glandu- 
lar structures,  which  disappear  in  part  or  entirely.  In  the  softer 
and  more  spongy  form  of  the  afiection,  all  of  the  constituents 
of  the  prostate  are  involved,  dilatation  and  epithelial  hyper- 
plasia of  the  acini  progressing  pari  passu  with  the  parenchyma- 
tous growth,  which  is  infiltrated  with  a  thick,  brownish  fluid, 
so  that  the  diti'erent  elements  bear  about  the  same  relation  to 
one  another  as  in  the  normal  organ.  In  no  instance,  however, 
has  the  development  of  new  glandular  elements  been  demon- 
strated. 

Senile  hypertrophy  generally  advances  very  tardily,  and  hence 

'  Medizinisclie  Jahrbiicher,  xiv.,  1867. 

2  The  Diseases  of  the  Prostate,  Phila.,  1873,  p.  139. 


HYPERTROPHY    OF    THE    PROSTATE.  399 

a  long  time  often  elapses  before  tlie  gland  attains  such  a  bulk  as 
to  lead  to  serious  inconvenience.  In  many  cases,  indeed,  after 
having  acquired  a  certain  magnitude,  its  progress  is  arrested, 
and  the  organ  remains  stationary  for  several  years,  if  not  during 
the  rest  of  life.  The  inflammatory  form,  on  the  contrary,  is 
usually  more  rapid  in  its  march,  and  may  attain  a  considerable 
height  in  a  few  months.  It  is  also  less  persistent  than  senile 
hypertrophy,  and  is  more  amenable  to  treatment. 

The  affection  is  usually  very  insidious  in  its  mode  of  invasion 
and  the  circumstances  attending  its  progress,  ^o  sj^mptoms 
indicative  of  its  seat  or  peculiar  character  show  themselves  until 
long  after  the  mischief  has  commenced.  Its  march  is  not  only 
slow,  but  eminently  stealthy  and  deceptive.  The  affection,  in  a 
word,  is  chronic  from  its  inception,  and  cannot,  without  great 
difficulty  and  circumspection,  be  distinguished,  in  its  earlier 
stages,  from  chronic  disease  of  the  bladder  and  the  urethra. 

Irritation  at  the  neck  of  the  bladder,  and  a  frequent  desire  to 
pass  the  urine,  are  the  symptoms  which  generally  first  attract 
the  attention  of  the  patient.  From  the  mildness,  however,  of 
their  character,  they  rarely  create  any  unpleasant  apprehensions, 
and  the  real  nature  of  the  disease,  therefore,  is  often  overlooked 
at  a  time  when  a  knowledge  of  it  is  of  paramount  importance. 
By  degrees  other  troubles  are  added,  and  it  is  in  this  manner 
that  he  is  finall}^  brought  to  a  full  sense  of  his  situation.  The 
distress  at  the  neck  of  the  bladder  becomes  more  constant,  as 
well  as  more  severe,  and  there  is  not  only  a  frequent  desire  to 
void  the  urine,  but  great  difficulty  in  starting  it.  The  stream 
also  is  unnaturally  feeble,  and  smaller  than  in  health.  Slight 
pain  is  felt  along  the  urethra,  accompanied  by  a  burning,  smart- 
ing, or  scalding  sensation  in  the  head  of  the  penis,  and  a  free 
discharge  of  prostntic  fluid.  In  consequence  of  the  frequent 
and  violent  straining  which  attends  micturition,  hemorrhoids, 
hernia,  and  prolapse  of  the  bowel  are  apt  to  occur;  and,  for  the 
same  reason,  the  feces  are  liable  to  be  voided  simultaneously 
with  the  urine.  The  mucous  membrane  is  sometimes  habitually 
everted  at  the  verge  of  the  anus,  and  exhibits  itself  in  the  form 
of  a  red,  tender  fold,  which  is  constantly  irritated  from  exposure 
to  the  atmosphere,  the  contact  of  acrid  secretions,  and  the  pres- 
sure of  the  adjacent  parts.  The  rectum  never  feels  entirely 
empty,  even  after  the  most  thorough  purgation,  but  as  if  it  con- 


400         HYPERTROPHY  OF  THE  PROSTATE. 

tained  a  lump  or  ball,  and  the  feces  are  often  passed  in  a  flattened 
form,  especially  if  they  happen  to  be  of  a  solid  consistence.  At 
night  the  patient  is  disturbed  by  an  involuntary  discharge  of 
seminal  fluid,  or  he  is  perhaps  harassed  with  erections  without 
emissions.  This  phenomenon  occasionally  exists  in  very  old 
men,  and  adds  greatly  to  the  local  distress.  The  testicles  some- 
times sympathize  with  the  aftected  gland,  becoming  very  tender, 
and  even  enlarged.  Hernia  may  also  be  produced  by  the  strain- 
ins;  which  attends   micturition. 

As  the  attection  advances,  the  symptoms  become  more  and 
more  aggravated,  although  they  are  still  essentially  the  sam«  in 
character.  The  desire  to  urinate  increases  in  frequency;  the 
bladder  is  less  patient  of  its  contents,  which  are  liable  to  esciipe 
involuntarily  at  night ;  the  pain  is  more  severe  and  constant,  as 
well  as  more  extensively  diti'used ;  micturition  is  attended  with 
greater  difliculty ;  and  the  prostate  is  the  seat  of  a  constant  feeling 
of  soreness.  The  general  health,  which  until  now  was,  perhaps, 
tolerably  good,  gradually  declines ;  the  appetite  fails ;  emacia- 
tion ensues ;  the  sufterer,  obliged  almost  incessantly  to  make 
water,  obtains  hardly  any  sleep;  and  the  constitution  is  at 
length  exhausted. 

The  pain  which  accompanies  this  affection  varies  in  different 
individuals,  and  in  the  same  person  under  different  circum- 
stances. It  is  not  in  proportion  to  the  size  of  the  organ,  but  to 
the  difliculty  in  expelling  the  urine.  It  is  generally  felt  most 
keenly  at  the  neck  of  the  bladder,  behind  the  pubes,  in  the 
urethra,  and  at  the  head  of  the  penis.  It  is  increased  by  exer- 
cise, the  erect  posture,  the  pressure  of  the  urine,  and  by  sexual 
intercourse.  In  most  cases,  it  extends  to  the  surrounding  parts, 
as  the  perineum  and  the  anus,  the  testes  and  spermatic  cords, 
the  sacrum,  loins,  thighs,  and  groins.  It  may  be  dull,  heavy,  or 
aching ;  throbbing  or  pulsatile ;  hot,  scalding,  or  burning ;  or 
sharp  and  darting,  as  in  neuralgia.  Very  often  it  is  of  a  spas- 
modic nature,  and  is  accompanied  by  the  most  violent  tenesmus. 
The  patient  sometimes  complains  of  a  "  bruised  feeling,"  or  of  a 
sense  of  soreness,  at  first  in  the  perineum,  and  afterwards  about 
the  anus,  in  the  thighs,  and  groins. 

A  very  unpleasant  symptom  of  this  affection  is  a  sense  of 
weight  or  fulness  in  the  pelvis,  and  a  feeling  as  if  the  bladder 
were  never  entirely  empty.     This  evidently  arises  from  two 


HYPERTROPHY    OF    THE    PROSTATE.  401 

Circumstances :  first,  from  the  pressure  of  the  enlarged  ghmd 
itself,  and,  secondlj',  from  the  presence  of  a  certain  quantity  of 
urine,  which  is  never  wholly  expelled,  no  matter  how  violent 
may  be  the  efforts  made  for  that  purpose.  The  fluid  which  is 
thus  retained  is  soon  decomposed,  and  thus  becomes  a  source  of 
irritation  both  to  the  bladder  and  the  affected  gland. 

The  urine,  at  first  perfectly  clear,  and,  to  all  appearance, 
natural,  becomes  gradually  changed  in  its  properties,  and  some- 
times even  in  its  quantity.  It  is  generally  thick,  fetid,  acrid, 
and  liighlj^  alkaline ;  depositing,  upon  standing,  a  great  abund- 
ance of  thick,  ropy,  purulent  mucus,  often  streaked  with  phos- 
phatic  matter,  and  always  firmly  adhering  to  the  bottom  of  the 
receiver.  The  fluid  is  soon  decomposed — indeed  it  is  frequently 
so  before  it  is  voided — and  then  always  exhales  a  strong  ammo- 
niacal  odor.  When  h3'pertroph3'  is  accompanied  by  ulceration 
of  the  prostate,  it  is  sometimes  tinged  with  blood.  The  quantity 
of  urine  may  be  natural,  increased,  or  diminished.  In  general, 
I  have  found  it  to  be  somewhat  increased. 

The  urine,  which  is  at  first  discharged  onl}^  six  or  eight  times 
a  day,  is  at  length  voided  every  hour,  every  half  hour,  or  even 
every  ten,  fifteen,  or  twenty  minutes.  During  the  act  of  mic- 
turition, the  patient  is  obliged  to  straddle  his  legs,  to  bend  his 
body  forwards,  and  to  make  the  most  violent  muscular  efforts  in 
order  to  accomplish  his  purpose.  He  strains  and  presses,  in  fact, 
with  all  his  might,  as  if  he  were  determined  to  expel  not  only 
his  urine,  but  his  bladder  along  with  it.  During  these  exertions 
feces  frequently  escape  involuntarily,  and  the  bowel  descends 
several  inches  below  the  anus ;  his  face  is  flushed,  and  his  eyes 
look  as  if  they  were  ready  to  protrude  from  their  sockets.  At 
last,  after  months  and  years,  perhaps,  of  the  most  horrible  suf- 
fering, the  urine  is  either  retained,  or  has  to  be  drawn  ott'  con- 
stantly with  the  catheter,  or  it  dribbles  away  incessantly,  the 
sphincter  being  no  longer  able  to  perform  its  office.  In  general, 
the  incontinence  of  urine  is  conjoined  with  retention ;  for,  as 
was  before  stated,  the  bladder  is  rarely,  if  ever,  wholly  emptied, 
on  account  of  the  increased  size  of  the  prostate  and  the  cul-de- 
sac  which  the  former  organ  presents  behind  the  latter. 

The  constitutional  symptoms  of  this  disease,  like  the  local,  are 
dependent  rather  upon  the  amount  of  sympathy  manifested  by 
the  surrounding  parts  than  upon  the  degree  of  enlargement  of 
26 


402  HYPERTROPHY    OF    THE    PROSTATE. 

the  prostate.  In  the  earlier  stages  there  is  little  or  no  fever,  and 
perhaps,  in  truth,  little  or  no  disorder  of  any  kind.  As  the  dis- 
ease progresses,  however,  the  health  manifestly  suffers ;  the  tongue 
is  coated,  the  pidse  is  irritahle,  the  sleep  is  disturbed  by  un- 
pleasant dreams,  the  skin  is  inclined  to  be  dry,  the  feet  are  cold 
in  the  day  and  hot  at  night,  the  appetite  is  deranged,  the  bowels 
are  irregular,  and  the  urine  is  acrid  and  high-colored,  at  times 
scanty,  and  at  other  times  preternatu rally  abundant.  Tliese 
symptoms,  as  well  as  the  local,  are  liable  to  temporary  aggrava- 
tion from  exjiosure  to  cold,  exercise  on  horseback,  venereal  indul- 
gence, stimulating  drinks,  and  higlily-seasoned  food. 

The  diagnosis  of  hypertrophy  of  the  prostate  is  generally  easy. 
When  an  individual  Avho  has  attained  the  age  of  fifty-five  or 
sixty  is  affected  with  the  train  of  symptoms  above  enumerated, 
the  presumption  is  strong  that  the  case  is  one  of  chronic  enlarge- 
ment of  this  body,  and  nothing  else.  The  aftections  vfitli  which 
it  is  most  liable  to  be  confounded  are  stricture  of  the  urethra, 
urinary  calculi,  catarrh  of  the  bladder,  and  stricture  of  the 
rectum.  All  that  is  necessarv  to  determine  the  diagnosis  is  a 
digital  examination  of  the  bowel. 

The  extent  to  which  the  gland  encroaches  upon  the  rectum  is 
variable ;  it  may  be  very  slight,  or  it  may  be  so  great  as  to  pro- 
duce partial  occlusion  of  the  tube,  and  consequently  more  or  less 
difiiculty  in  defecation.  The  tumor  is  usually  easily  felt  by  the 
finger,  and  rarely  exceeds  the  volume  of  a  pullet's  egg;  it  may 
be  as  big,  however,  as  a  middle-sized  orange,  or  even  as  a  small 
fist.  It  is  conmionly  larger  on  one  side  than  on  the  other,  and 
feels  like  a  hard,  solid  substance,  the  surface  of  which  is  either 
smooth  and  uniform,  or  knobby  and  irregular.  In  the  earlier 
stages  of  the  disease,  the  gland  may  generally  be  pushed  a  little 
upwards  and  to  either  side ;  but  when  it  is  much  enlarged,  it  is 
immovably  fixed  behind  and  below  the  arch  of  the  pubes,  and 
imparts  to  the  finger  the  sensation  of  a  hard,  firm,  and  inelastic 
body.  The  lateral  lobes  are  always  more  easily  distinguished 
than  the  middle,  wdiich,  when  much  augmented  in  volume,  is 
frequently  dragged  up  so  high  as  to  be  entirely  beyond  the  reach 
of  even  the  lono-est  fintcer. 

Valuable  information,  in  regard  to  the  size  and  shape  of  the 
tumor,  may  generally  be  obtained  by  an  exploration  of  the 
prostate  with  the  sound  represented  in  fig.  51.     The  instrument. 


HYPEETKOPHY    OF    THE    PROSTATE.  403 

warmed  and  well  oiled,  is  introduced  in  the  usual  manner  until 
it  reaches  the  neck  of  the  hladder,  where,  if  there  be  any  con- 
siderable enlargement,  it  will  be  almost  sure  to  be  arrested,  and 
to  convey  to  the  linger  the  sensation  as  if  it  were  pressing  against 
a  solid  and  resisting  body.  To  surmount  this  obstacle,  wdiich 
may  be  either  directly  in  the  middle  line,  or  towards  either  side, 
according  as  it  is  produced  hy  the  middle  lobe,  or  by  one  or  both 
of  the  lateral  masses,  it  is  generally  necessary  to  insert  the  left 
index-linger  into  the  rectum,  and  to  use  it  to  guide  the  instru- 
ment on  into  the  bladder. 

The  conduct,  if  I  may  use  the  expression,  of  the  instrument, 
as  it  passes  along  the  neck  of  the  bladder,  will  be  influenced  by 
the  character  and  extent  of  the  hypertrophy,  and  is  deserving  of 
particular  attention.  If  the  middle  lobe  alone  is  affected,  the 
obstruction  wall  be  found  at  the  middle  line,  and  the  handle  will 
have  to  be  considerably  depressed  to  enable  the  beak  to  glide 
over  it  into  the  bladder.  In  addition  to  this  it  may  be  necessary, 
as  above  stated,  to  insert  the  linger  into  the  rectum,  in  order  to 
push  the  curved  portion  of  the  instrument  close  against  the  pubic 
arch.  To  ascertain  the  size  of  the  tumor,  the  vesical  extremity 
of  the  sound  is  hooked  over  its  posterior  surface,  and  passed 
successively  around  its  sides,  the  linger  being  still  in  the  bowel, 
and  placed  against  the  beak.  When  both  the  lateral  masses  are 
enlarged  equally  at  their  inner  margins,  unaccompanied  by  hyper- 
tropliy  of  the  rest  of  the  organ,  the  passage  will  retain  its  normal 
course,  and  the  instrument  will  advance  in  a  straight  line,  just 
as  it  does  in  the  healthy  state  of  the  parts.  If,  on  the  contrary, 
the  growth  be  unequal,  the  canal  will  incline  to  one  side,  and  the 
deformity  will  be  indicated  by  a  corresponding  change  in  the 
direction  of  the  instrument.  Sometimes  a  double  curve  exists, 
one  being  formed,  for  instance,  by  the  right  lobe,  and  the  other 
by  the  left ;  or,  there  may  be  two  projections  on  one  side  with 
two  corresponding  depressions  on  the  opposite. 

Ilypertroiihy  of  the  prostate,  especially  wdien  it  exists  in  any 
considerable  degree,  is  rarely  unaccompanied  by  more  or  less 
suffering  of  the  adjacent  parts.  The  organ  wdiich  is  most  liable 
to  be  implicated  is  the  bladder,  the  muscular  coat  of  which  be- 
comes greatly  tliickened  and  fasciculated,  in  consequence  of  the 
mechanical  obstruction  afforded  by  the  prostate  to  the  evacuation 
of  the  urine.     For  the  same  reason,  tlie  mucous  membrane  is 


404  HYPERTROPHY    OF    THE    PROSTATE. 

always  in  a  state  of  chronic  inflammation,  and  sometimes  mam- 
millated,  ulcerated,  or  even  sacculated.  Another,  and  not  very 
uncommon,  effect  is  the  formation  of  urinary  calculi.  When 
this  event  occurs,  two  circumstances,  worthy  of  notice,  are  liable 
to  take  place:  one  is,  that  the  stone  is  productive  of  less  sutiering 
from  its  inability  to  fall  against  the  orifice  of  the  urethra,  and 
thus  impede  the  discharge  of  the  urine;  and  the  other,  that  it 
is  more  difficult,  from  its  concealed  situation  behind  the  prostate, 
to  extract  it. 

The  urethra,  during  the  progress  of  this  disease,  often  under- 
goes important  alterations,  which  are  liable  to  be  followed  by 
serious  difficulty  as  it  respects  the  evacuation  of  the  urine  and 
the  introduction  of  the  catheter  and  other  instruments.  These 
changes,  which  are  deserving  of  attentive  consideration,  are 
limited  exclusively  to  the  posterior  part  of  the  canal,  or  that 
portion  of  it  which  is  surrounded  and  embraced  by  the  prostate, 
and  are  referable  mainly  to  the  dimensions,  direction,  and  form 
of  the  passage. 

Elongation  of  the  prostatic  portion  of  the  urethra  exists  nearly 
always  in  tlie  more  aggravated  forms  of  hypertrophy  of  this  gland. 
It  varies  in  degree  from  a  few  lines  to  two  inches,  which,  how- 
ever, it  rarely  attains.  With  this  addition  from  disease,  this 
portion  of  the  canal  may  acquire  a  length  of  two  inches,  two 
inches  and  a  half,  and,  in  extraordinary  cases,  even  three  inches. 
Mr.  Guthrie^  mentions  an  instance  in  whicii  the  elongation  was 
nearly  four  inches,  requiring  a  proportionately  long  catheter  to 
draw  oft"  the  urine.  With  such  an  example,  which  is  of  course 
an  extreme  one,  I  have  never  met.  The  increase  of  length  may 
be  produced  by  hypertrophy  of  the  lateral  masses  alone,  by  the 
middle  lobe  alone,  or,  as  more  commonly  happens,  by  the  joint 
agency  of  all  these  parts.  When  enlargement  of  the  middle  lobe 
predominates,  the  urethra  is  dragged  up  behind  the  pubic  arch, 
and  is  thus  proportionately  augmented  in  length,  at  the  same 
time  that  it  generally  presents  a  falciform  curve,  the  convexity 
of  which  looks  towards  the  rectum,  as  represented  in  fig.  119, 
from  Thompson. 

When  the  lateral  masses  alone  are  affected,  in  an  equal  de- 
gree, the  intervening  canal  may  retain  its  natural  size  and  shape, 

'  Op.  cit.,  p.  235. 


HYPERTROPHY    OF    THE    PROSTATE, 


405 


or  it  may  change  its  form,  and  become  either  diminished  or 
increased  in  its  dimensions.  In  a  specimen  in  ni}^  cabinet,  in 
which  tliere  is  no  appearance  whatever  of  a  middle  lobe,  but 
in  which  both  the  lateral  portions  are  considerablj^  augmented  in 


Fiir.  119. 


Angular  Curvature  of  the  Urethra  from  Hypertrophy  of  the  Prostate. 

volume,  the  prostatic  part  of  the  urethra  is  merel}^  increased  in 
length,  while  its  form  and  size  are  apparently  perfectly  normal. 
From  all  absence  of  hypertrophy  of  the  muscular  coat  of  the 
bladder,  it  is  evident  that  there  was  no  obstruction  during  life 
to  the  evacuation  of  the  urine.  It  is  only,  indeed,  in  cases  whei-e 
the  increase  of  development  takes  place  at  the  inner  margins  of 
the  lateral  lobes  that  the  sides  of  the  canal,  embraced  by  them, 
will  approach,  and  ultimately  be  brought  into  apposition  with 
each  other ;  a  condition  always  accompanied  by  partial  or  com- 
plete retention. 

In  hypertrophy  of  all  the  constituent  parts  of  the  prostate,  the 
included  portion  of  the  urethra  generally  presents  itself  in  the 
form  of  a  vertical  slit,  which  in  some  of  my  examinations  I  have 
found  to  be  fully  three-quarters  of  an  inch  in  depth,  that  is,  in 
the  recto-pubic  direction,  while  its  sides  were  occasionally  almost, 
if  indeed  not  quite,  in  contact  with  each  other,  as  in  fig.  120, 
from  a  specimen  in  my  collection.     In  such  a  case  as  this  the 


406 


HYPERTROPHY    OF    THE    PROSTATE. 


obstruction  must  necessarily  be  attended  with  more  or  less  im- 
pediment to  the  discharge  of  the  urine,  and  hypertrophy  of  the 
muscular  fibres  of  the  bladder. 


Fig.  120. 


Vertical  Elongatioo  of  tlie  Urethra  from  Hy^iertropby  uf  the  Prostate. 

In  a  second,  series  of  cases  of  universal  hypertrophy,  the  pros- 
tatic portion  of  the  canal  is  materially  increased  in  its  diameter, 
evidentl}^  by  the  projection  of  the  middle  lobe  between  the  two 
lateral,  the  edges  of  which  are  thus  kept  permanently  asunder. 
This  state,  which  occasionally  exists  to  a  great  and  deplorable 
extent,  is  often  accompanied  with  incontinence  of  urine,  which, 
under  such  circumstances,  is  liable  to  be  ascribed  to  paralysis  of 
the  bladder. 

Lateral  curvature  of  the  canal  is  generally  dependent  upon  an 
unequal  eidargement  of  the  inner  edges  of  the  lateral  lobes.  An 
unusual  projection  on  one  side  will  necessarily  encroach  in  a 
corresponding  degree  upon  the  other  side,  followed  by  a  propor- 
tionate deviation  from  the  median  line.  •  The  curvature,  Avhich 
seldom  exists  in  a  high  degree,  is  sometimes  double;  occasionally* 
it  is  accompanied  by  a  sort  of  contorted  or  twisted  state  of  the 
urethra. 

The  form  and   dimensions  of  the  vesico-urethral  orifice,  or 


HYPERTROPHY    OF    THE    PROSTATE.  407 

mouth  of  the  urethra,  are  considerahly  influenced*- hy  the  nature 
of  the  hypertrophy.  When  both  lobes  are  equally  and  alone 
enlarged,  it  is  generally  circular,  and  but  little,  if  any,  diminished 
in  size.  Frequentl}'  it  presents  itself  as  a  narrow,  vertical  slit, 
not  unlike  the  chink  of  the  glottis.  This  condition  generally 
accompanies  hypertrophy  of  the  inner  edges  of  the  lateral  lobes, 
and  antero-posterior  enlargement  of  the  prostatic  part  of  the 
urethra.  In  a  third  series  of  cases,  it  has  very  much  the  shape 
and  appearance  of  the  mouth  of  a  pitcher  closed  by  its  lid  ;  that 
is,  it  is  a  transverse  fissure,  bounded  in  front  and  at  tlie  sides  by 
the  lateral  lobes,  and  behind  by  the  enlarged  central  mass. 

Lateral  deviation  of  the  urethra  is  sometimes  produced  by  an 
irregular  development  of  the  middle  lobe,  the  remainder  of  the 
gland  being  unaffected.  In  this  manner  one  of  the  lateral 
masses  is  pushed  to  one  side,  followed  by  a  corresponding  bend 
in  the  canal,  which  is  always  most  conspicuous  at  its  posterior 
extremity.  Finally,  when  the  middle  lobe  is  of  unusual  volume, 
the  canal,  as  it  extends  backwards,  becomes  sometimes  bilid,  or 
separated  into  two  grooves,  bounded  each  by  the  contiguous 
surfaces  of  the  middle  and  lateral  masses. 

The  ureters  are  seldom  entirely  sound.  The  most  common 
lesions  are  shortening  and  dilatation,  or  alternate  dilatation  and 
contraction,  with  irregular  thickening  or  attenuation  of  their 
walls.  The  kidne\'s  are  lialde  to  chronic  inflammation,  attended 
with  changes  of  structure,  size,  and  shape,  and  in  some  cases  they 
undergo  cystic  degeneration.  The  seminal  vesicles  and  testicles 
are  occasionally  involved,  and  it  rarely  happens  that  the  rectum 
is  free  from  disease. 

N'ot withstanding  the  numerous  attempts  that  have  been  made 
from  time  to  time  to  place  the  treatment  of  this  aflection  upon 
a  scientific  basis,  it  must  be  confessed  that  it  is  eminently  em- 
pirical, tentative,  and  unsatisfactory.  These  remarks  are  par- 
ticularly true  of  the  senile  form  of  the  complaint,  which  hardly 
ever  yields  to  any  mode  of  treatment,  however  judiciously  de- 
vised or  perseveringly  employed.  The  disorder,  in  this  respect, 
bears  a  close  resemblance  to  certain  kinds  of  morbid  growths, 
which,  when  once  developed,  are  utterly  beyond  the  reach  of 
medicine ;  no  remedies  exert  the  slightest  influence  upon  their 
progress ;  nothing  can  change  their  character,  modify  their 
action,  or  suspend  their  nutrition.     The  malady  progresses  in 


408  HYPERTROPHY    OF    THE    PROSTATE. 

spite  of  the  best-directed  efforts  of  the  surgeon,  and  only  ceases 
with  life. 

If  the  patient  be  plethoric,  the  enlargement  considerable,  and 
tlie  sympathetic  reaction  great,  no  remedy  will  be  so  likely  to 
afford  prompt  and  decided  relief  as  the  abstraction  of  blood  from 
the  i»erineum  by  leeches.  This  is  true,  whatever  may  be  the 
character  of  the  hypertrophy.  The  detraction  of  blood  should 
always,  in  the  more  aggravated  varieties  of  the  complaint,  be 
speedily  followed  by  the  use  of  the  antimonial  and  saline  mix- 
ture, in  the  hope  of  subduing  the  action  of  the  heart,  unlocking 
the  secretions,  and  clearing  out  the  bowels.  All  irritating  or 
griping  cathartics  must  here,  as  in  most  of  the  other  affections 
of  the  prostate,  be  entirely  proscribed.  Aloetic  and  other  pre- 
parations having  a  particular  tendency  to  the  rectum,  are  to  be 
avoided.  At  the  same  time,  it  must  be  borne  in  mind  that  an 
overloaded  state  of  the  bowels  is  never  j)ermissible  ;  on  the  con- 
trary, it  is  to  be  carefully  guarded  against,  for  it  can  never  exist 
for  any  length  of  time  without  producing  an  increase  of  irrita- 
tion, if  not  positive  mischief.  Sulphate  of  magnesia,  or  jalap 
and  bitartrate  of  potassa,  by  rendering  the  feces  soft  and  watery, 
are  particularly  well  adapted  to  cases  of  such  a  nature.  Where 
manifest  disorder  of  the  biliary  secretion  exists,  a  few  grains  of 
calomel  will  generally  prove  serviceable.  Sometimes  a  laxative 
enema  answers  a  good  pjurpose,  and  obviates  the  necessity  of 
giving  this  kind  of  medicine  by  tlie  mouth. 

The  food  should  be  perfectly  plain,  easily  digestible,  and  unir- 
ritating.  It  should  be  well  masticated,  and  be  free  from  all 
stimulating  admixtures.  Condiments  of  every  description,  wine, 
brandy,  and  fermented  drinks,  are  carefully  avoided.  Unless 
strict  attention  be  paid  to  these  rules,  no  reasonable  hope,  even 
of  temporary  amendment,  can  be  indulged. 

All  the  exciting  causes  of  the  disease  are  to  be  carefully 
avoided.  Above  all,  it  is  necessary  that  the  patient  should 
abstain  from  horseback  exercise  and  from  sexual  intercourse. 
From  the  tendency  which  these  pursuits  have  to  produce  en- 
gorgement of  the  prostate  and  the  rectum,  I  am  satisfied  that 
too  much  stress  cannot  be  laid  upon  their  prohibition.  I  would 
even  go  so  far,  in  all  cases,  as  to  make  the  injunction  absolute. 
Where  the  passions  are  unusually  strong,  and  the  desire  for 
sexual  intercourse  is  very  frequent,  and  almost  unconquerable, 


HYPERTROPHY    OF    THE    PROSTATE.  409 

as  it  very  often  is  in  persons  laboring  under  this  complaint,  it 
may  be  necessary  for  a  time  to  interdict  female  society,  until,  by 
proper  treatment,  the  feeling  in  question  is  subdued.  The  in- 
flammatory form  of  the  complaint,  de})endent  upon  stricture, 
calculus,  or  chronic  prostatitis,  generally  disappears  rapidly 
upon  the  removal  of  these  complaints. 

Repose  in  the  horizontal  posture  is  hardly  less  necessary  here 
than  it  is  in  the  more  acute  affections  of  the  prostate.  By  this 
remark,  I  do  not,  of  course,  mean  that  the  patient  shall  conline 
himself  constantly  to  his  bed,  and  avoid  all  exercise — by  no 
means ;  on  the  contrary,  he  should  not  neglect,  whenever  the 
weather  is  pleasant,  to  stir  about  for  a  few  hours  every  day  in 
the  open  air,  either  on  foot,  or  in  an  easy  carriage.  When  in 
the  house,  he  may  lie  upon  a  lounge,  or  recline  upon  an  easy 
chair  with  a  movable  back.  In  either  case,  flannel  must  be 
worn  next  the  skin,  and  exposure  to  cold  be  avoided. 

For  the  purpose  of  acting  directly,  as  it  were,  upon  the  gland, 
and  thereby  lessening  its  volume,  various  remedies  have  been 
proposed.  Among  the  more  important  of  these  are,  iodine  and 
its  difterent  combinations,  cicuta,  mercury,  hydrochlorate  of 
ammonia,  local  depletion,  and  counter-irritation  by  issues,  setons, 
blisters,  and  tartar-emetic  pustulation.  Of  these  remedies,  it 
may  be  observed,  in  general  terms,  that  their  eflicaey  has  been 
fully  tested  by  ditterent  observers,  and  that  they  are  all  to  be 
regarded  in  the  light  merely  of  palliatives.  I  have  myself  never 
witnessed  any  relief  from  their  employment. 

Ergot  is  a  favorite  remedy  with  my  friend  Dr.  Washington 
L.  Atlee,  of  this  city,  in  the  treatment  of  this  afteetion.  In  a 
recent  communication  to  me,  this  distinguished  surgeon  states 
that  he  is  in  the  habit  of  administering  twenty  drops  of  the 
fluid  extract  of  ergot  every  four  hours,  its  action  being  supple- 
mented by  the  use  of  the  catheter  twice  daily,  until  the  patient 
regains  entire  control  over  the  bladder.  As  the  power  to  urinate 
is  restored,  the  frequency  of  the  dose  is  diminished,  and  ulti- 
mately reduced  to  a  single  administration  at  bedtime.  Several 
patients,  whose  ages  ranged  between  sixty  and  ninety  3'ears, 
were  enabled,  under  this  treatment,  to  lay  aside  the  catheter, 
after  having  been  the  victims  of  its  daily  use.  A  gentleman,  of 
eighty-nine,  whose  treatment  was  commenced  in  August,  1872, 
by  the  methodical  evacuation  of  the  bladder,  and  Avhose  death 
seemed  to  be  imminent,  has  for  the  last  three  years  maintained 


410  HYPERTROPHY    OF    THE    PROSTATE. 

his  general  liealthaiid  his  urinaiy  organs  in  excellent  condition, 
by  the  evening  dose  of  the  remedy.  Apart  from  the  evidence 
afforded  by  the  experience  of  so  trustworthy  an  observer,  ergot 
should,  on  theoretical  grounds,  be  well  calculated  to  aftbrd  relief 
to  a  hj-pertrophied  prostate,  in  the  same  way  that  it  acts  on 
uterine  myomata.  The  nutrition  of  the  organ  being  aft'ected 
by  the  contraction  of  its  bloodvessels  and  its  muscular  fibres, 
there  should  be  a  corresponding  diminution  of  its  volume. 

Tlie  only  local  treatment  deserving  of  mention  is  that  by 
injecting  the  gland,  through  the  anterior  wall  of  the  rectum,  with 
solutions  of  iodine,  to  which  attention  has  recently  been  directed 
by  Professor  Heine,  of  Innsbruck.^  The  patient  being  placed 
on  his  side,  with  the  limbs  retracted,  a  long,  delicate  exploratory 
trocar,  guided  by  the  index  finger,  is  successively  inserted  to 
the  depth  of  two  lines  into  each  lateral  lobe  a  little  to  one  side 
of  the  median  furrow,  in  order  to  avoid  a  small  artery  which  is 
frequentl}'  found  in  that  situation,  when  a  Pravaz's  syringe  is 
passed  into  the  canula,  and  from  twelve  to  tw^enty  drops  of  a 
solution,  composed  of  two  drachms  of  iodide  of  potassium,  two 
ounces  of  tincture  of  iodine,  and  six  ounces  of  water,  slowly 
thrown  in.  The  operation  is  to  be  repeated  at  intervals  of  seven 
to  fourteen  days.  Of  six  cases  treated  in  this  w^ay,  in  only  one 
was  there  inflammatory  reaction  and  the  formation  of  an  abscess, 
which  opened  spontaneously  on  the  eighth  day,  and  was  fol- 
lowed by  almost  complete  atrophy  of  the  gland.  In  a  second 
case,  in  which  from  exposure,  there  was  a  return  of  the  vesical 
sj-mptoms,  three  additional  injections  were  practised.  On  death 
from  pneumonia,  Avitli  purulent  cystitis  and  pyelitis,  a  small 
abscess  was  found  between  the  rectum  and  the  i)rostate,  Avliich 
was  probably  due  to  the  fluid  having  escaped  into  the  connective 
tissue.  In  the  remaining  cases,  the  immediate  effects  of  the 
remedy  were  great  palliation  of  the  symptoms  of  obstruction,  and 
diminished  frequency  of  micturition,  with  palpable  involution 
of  the  gland.  One  died,  in  a  fortnight,  from  exhaustion  pro- 
duced by  previous  disease,  and  there  were  no  evidences  of  suppu- 
ration.    In  the  other  three,  the  sj-mptoms  were  greatly  relieved. 

This  plan  of  treatment  deserves  more  extended  trial ;  but  the 
risks  of  suppuration,  which  is  so  frequent  a  result  of  injections 
into  the  parenchyma  of  other  organs,  must  be  borne  in  mind. 

'  Langenbeck's  Archiv,  Bd.  xv.  p.  88,  and  Bd.  xvi.  p  79. 


HYPERTROPHY    OF    THE    PROSTATE.  411 

Finally,  the  patient  must  pay  particular  attention  to  the  time 
and  manner  in  which  he  voids  his  urine.  Indeed,  at  the  ap- 
proach of  the  first  symptoms,  he  should  he  taught  the  introduc- 
tion of  the  soft,  vulcanized  catheters,  represented  on  page  114, 
through  the  systematic  use  of  which,  complications,  as  cystitis, 
calculous  disease,  atony  of  the  bladder,  and  dilatation  of  that 
organ,  the  ureters,  and  kidneys,  may  he  prevented.  If  the 
amount  of  residual  urine  be  small,  the  instrument  need  not  be 
employed  oftener  than  twice  a  day;  but  if  it  be  large,  the  urine 
should  be  drawn  otf  every  six  hours,  any  considerable  accumula- 
tion being  likelj'  to  prove  a  source  of  irritation,  if  not  of  actual 
disease  of  the  aifected  parts.  For  the  same  reason,  injection  of 
the  bladder,  as  advised  under  the  head  of  cystorrhoea,  often  pro- 
duces great  relief  by  dislodging  the  thick,  ropy,  and  oftensive 
secretion,  which  so  often  collects  in  the  bas-fond  of  the  bladder. 

When  the  obstruction  to  micturition  is  complete,  and  the 
capacity  of  the  bladder  is  greatly  diminished,  so  that  a  resort  to 
the  catheter  becomes  necessary  nearly  every  hour,  rendering  the 
condition  of  the  patient  one  of  extreme  misery,  with  rapid  fail- 
ure of  the  strength,  the  permanent  retention  of  a  tube  in  the 
bladder  above  the  pubes,  may  be  advisable  to  avert  impending 
death.  An  opportunity  is  thus  aflbrded  to  the  water  to  drain 
off  almost  as  fast  as  it  is  secreted,  and  the  bladder,  placed  in  an 
easy,  quiet  state,  is  prevented  from  constantly  contracting  on  its 
contents.  When  the  obstacle  to  the  passage  of  the  urine  depends 
upon  enlargement  of  the  middle  lobe,  and  the  patient  is  in  fair 
general  health,  I  can  see  no  objection  to  excising  it.  The  opera- 
tion could  hardly  fail,  when  that  body  is  attached  by  a  pedicle, 
and  might  afford  the  only  chance  of  relief.  I  should  certainly 
myself  prefer  it,  in  such  an  event,  to  the  operation  of  crushing, 
recommended  b}^  some  of  the  French  surgeons,  and  to  the  foi*- 
mation  of  an  artificial  urinary  fistule  above  the  pubes.  In 
executing  the  operation,  the  incisions  would  have  to  be  the  same 
as  in  the  lateral  operation  of  lithotomy,  and  the  enlarged  lobe 
could  be  easily  cut  away  at  its  base  with  a  probe-pointed  bistoury, 
or  a  pair  of  stout,  probe-pointed  scissors,  curved  on  the  flat. 
That  it  Avould  not  be  attended  with  any  very  grave  risks,  is 
attested  by  several  examples,  referred  to  in  the  chapter  on  Tumors 
of  the  Prostate,  in  which  the  median  lobe  was  removed  during 
the  operation  for  vesical  calculus. 


CHAPTER  IV. 

ATROPHY  OF  THE  PROSTATE. 

The  prostate,  like  other  organs,  is  liable  to  atrophy.  As  an 
eft'ect  of  senile  deca}',  it  exists  in  about  nine  per  cent,  of  all  per- 
sons above  fifty  years  of  age,  when  it  is  usuall}^  complicated 
with  disorder  of  the  bladder,  or  of  the  bladder  and  urethra.  It 
may  result  from  exhausting  diseases,  as  pulmonary  phthisis  and 
protracted  diarrhoea,  and  it  is  also  met  with  in  eunuchs.  The 
affection  is,  however,  generally  the  result  of  mechanical  com- 
pression, or  structural  disorganization.  Thus,  a  calculous  con- 
cretion, either  developed  in  the  gland  itself,  or  lying  habituall}' 
at  the  neck  of  the  bladder,  or  the  presence  of  a  tumor  in  its 
immediate  vicinity,  may,  by  the  pressure  which  they  exert  upon 
tlie  prostate,  lead  to  gradual  absorption  of  its  glandular  and 
other  elements,  attended  with  great  diminution  of  its  volume. 
A  similar  change  is  sometimes  brought  about  by  an  abscess,  or 
a  tubercular  deposit,  and  it  is  not  infrequently  met  with  incases 
of  tight  stricture  of  the  urethra,  in  which  hydrostatic  pressure 
is  exerted  upon  the  organ  by  the  urine  contained  in  the  sac 
formed  by  the  dilated  canal. 

The  extent  of  the  atrophy  varies.  It  may  involve  the  entire 
gland,  one  of  its  lobes,  or  only  a  part  of  a  lobe.  In  extreme 
cases  the  proper  structure  is  almost  entirely  eifaced,  and  hardly 
anything  remains  but  its  fibrous  capsule,  the  weight  being 
reduced  two-tliirds  Or  three-fourths.  In  the  more  ordinary 
forms,  liowever,  the  gland  is  only  somewhat  diminished  in 
bulk,  preternaturally  firm,  and  of  a  paler  color  than  in  the  nor- 
mal state. 

Of  the  symptoms  and  treatment  of  the  aftection  nothing  is 
known.  In  emaciated  persons,  when  there  is  coincident  atrophy 
of  the  sphincter  muscle  of  the  neck  of  the  l)ladder,  complete 
incontinence  of  urine  may  declare  itself.  Whenever  the  excit- 
ing cause  can  be  determined,  its  removal  may  have  a  good  etlect 
upon  the  condition  of  the  gland. 


CHAPTER    V. 

TUMORS  AND  TUBERCLE  OF  THE  PROSTATE, 

Sect.  I.— TUMORS  OP  THE  PROSTATE. 

The  occurrence  of  cj^sts  and  new  growths  of  the  prostate  is 
rare.  Of  tlie  latter,  the  most  common  and  important,  from  a 
practical  point  of  view,  are  fihromatous  myoma,  medullary  or 
encephaloid  carcinoma,  and  encephaloid  sarcoma. 

a.  Cystic  Tumors. — The  prostate  is  occasionally  the  seat  of 
retention  cysts,  dependent  upon  obstruction  of  its  ducts,  with 
dilatation  of  these  canals  and  their  terminal  acini,  and  retention 
of  their  contents,  which  are  of  a  clear,  or  opaline,  viscid,  mucous 
nature.  Thus  formed,  the  cysts  vary  in  size  from  a  millet  seed 
to  that  of  a  pea,  or  even  a  hazel  nut.  In  general,  there  are  not 
more  than  six  or  eight ;  and  examples  occur  in  which  there  is 
only  one,  which  is  then  proportionately  large,  occupying,  per- 
haps, one-third  of  the  entire  gland.  The  organ  itself  is  usually 
hypertrophied,  and  dense  in  its  structure  ;  but  its  parenchyma 
is,  in  great  measure,  absorbed,  when  the  cysts  are  large  or  nume- 
rous. Nothing  is  known  of  their  progress,  termination,  and 
treatment. 

A  second  form  of  retention  cyst,  to  which  attention  has  been 
especially  directed  by  Dr.  Joseph  Englisch,^  of  Vienna,  is  that 
due  to  congenital  occlusion  of  the  orifice  of  the  sinus  pocularis 
in  the  prostatic  urethra,  and  the  accumulation  of  the  secretion 
of  the  numerous  small  glands  which  open  on  its  inner  surface. 
A  knowledge  of  this  variety  of  tumor  is  not  devoid  of  practical 
interest,  since  a  part,  at  least,  of  the  cases  of  retention  of  urine 
in  the  new-born  child  may  be  traced  to  this  cause.  Dr.  Englisch 
met  with  this  anomaly  in  seven  percent,  of  numerous  dissections 
of  infants,  the  sac  of  the  utricle  either  being  distended  and  en- 
croaching upon  the  urethra,  or  projecting,  as  a  fluctuating 
swelling,  behind  the  posterior  margin  of  the  prostate,  in  the 

'  Strieker's  Medizinische  Jahrbiicher,  1873,  Heft  i.,  aucl  1874,  Heft  ii. 


414    TUMORS  AND  TUBERCLE  OF  THE  PROSTATE. 

recto-prostatic  space,  or  even  extending  as  high  up  as  the  recto- 
vesical reflection  of  the  peritoneum. 

Compared  with  the  size  of  the  prostate  at  birth,  these  forma- 
tions attain  Large  dimensions,  and  give  rise  not  only  to  difficulty 
or  impossibility  of  micturition,  but  also  awaken  secondary 
changes  in  the  associated  organs.  In  all  the  cases  cited  by  the 
Viennese  pliysician,  the  bladder  was  distended,  and  its  muscular 
walls  hypertrophied ;  the  ureters  and  pelves  of  the  kidneys  were 
dilated,  and  the  walls  of  the  former  were  thickened,  while  the 
latter  were  inflamed  or  atrophied.  These  efl:ects  depend  less  upon 
the  volume  of  the  cyst  than  upon  its  location;  and  are  far  worse 
when  the  obstruction,  however  slight,  is  seated  at  the  anterior 
portion  of  the  sinus,  than  when  the  cyst  projects  backwards 
towards  the  rectum. 

In  the  absence  of  congenital  atresia  of  the  urinary  meatus,  or 
imperforate  prepuce,  the  existence  of  utricular  retention  cysts 
in  the  new-born  child,  may  be  suspected  from  retention  of  urine, 
and  the  presence  of  the  distended  bladdder  above  the  pubes. 
The  occlusion  is  sometimes  so  slight  that  the  infant  is  able  to 
overcome  it  by  involuntary  straining ;  but  should  this  not  be 
the  case,  the  introduction  of  a  silver  catheter  will  suffice  to 
evacuate  the  cj'st  and  relieve  the  bladder.  In  the  event  of  a 
small  fluctuating  tumor  being  detected  by  the  fino-er  in  the 
rectum,  it  should  be  punctured  with  a  delicate  trocar. 

j3.  Fibromatous  Myoma.  — Fibromuscular  neoplasms,  the  so- 
called  prostatic  glandular  tumors,  are  seldom  met  with  in  the 
normal  prostate ;  but  they  are  generally  present  in  the  hyper- 
trophied organ  of  old  persons,  either  as  discontinuous  or  con- 
tinuous growths.  In  the  first,  and  by  far  the  most  frequent,  form, 
section  of  the  piostate  discloses  one  or  more  rounded  or  ovoidal 
nodules,  rarely  exceeding  six  lines  in  diameter,  imbedded  in  its 
parenchyma,  and  surrounded  by  a  distinct  capsule  of  fibrous 
tissue,  from  which  it  can  be  readily  enucleated.  They  are  usually 
solitary,  and  situated  towards  the  outer  surface  of  the  posterior 
margin  of  the  lateral  lobes,  although  they  may  project  inwards 
and  encroach  upon  the  urethra,  imparting  to  its  lumen  the 
variations  in  size  and  shape,  which  have  been  already  noticed  in 
a  preceding  chapter.  When  they  are  seated  at  the  periphery  of 
the  organ,  they  frequently  give  it  a  bosselated  or  lobulated  out- 
line, which  may  be  detected  by  rectal  palpation.     Section  of  the 


TUMORS    OF    THE    PROSTATE.  415 

larger  nodules  displays  a  grayish  or  drab-colored  homogeneous 
tissue,  of  a  tough,  inelastic  character,  having  little  moisture, 
and  only  a  few  vessels.  The  smaller  growths,  on  the  other 
hand,  are  of  a  soft,  elastic  consistence,  and  of  a  reddish-gray 
complexion. 

In  the  second  variety,  the  tumor  occurs  as  a  continuous,  hut 
outljnng,  mass,  which  is  generally  connected  with  the  middle 
lobe  of  the  prostate  by  a  more  or  less  delicate  pedicle.  Resembling 
a  polyp  in  its  configuration,  it  may  attain  the  size  of  a  chestnut 
or  an  egg,  and  it  now  and  tlien  contains  concretions,  and  even 
small  isolated  nodules.  Projecting  into  the  cavity  of  the  bladder, 
it  may  move  on  its  attachment  like  a  hinge  or  valve,  and  in  this 
way  act  obstructingly  to  the  discharge  of  the  urine.^ 

In  their  histological  construction,  these  growths  are  homolo- 
gous with  the  proper  prostatic  tissues,  and  tbeyhave  their  ana- 
logues in  the  tumors  met  with  in  the  uterus,  the  onl}^  point  of 
ditlerence  being  that  they  do  not  undergo  calcareous,  cystic,  or 
telangiectoid  degeneration.  The  softer  outlying  variety  usually 
contains  glandular  elements,  which  are  absent  in  the  intrapros- 
tatic  nodules. 

The  existence  of  fibromatous  myomas  may  be  suspected  during 
life;  but  they  occasion  no  symptoms  by  which  their  presence 
can  be  positively  determined.  The  isolated  growths  are  not  in- 
frequently exposed  by  the  surgeon  during  the  lateral  section  of 
the  prostate  in  lithotomy  ;  and,  although  their  accidental  enu- 
cleation does  not  appear  to  entail  any  serious  consequences,  the 
advice  of  some  surgeons  to  remove  them,  with  a  view  of  having 
less  surface  for  suppuration  and  granulation,  and  diminishing 
the  volume  of  the  organ,  should  not  be  followed.  Instead  of 
expediting  healing,  their  extirpation  retards  this  process,  and 
leads  to  the  formation  of  a  pouch,  which  acts  as  a  su[)plementary 
bladder,  thereby  increasing  the  difficulty  in  voiding  the  urine,^ 
and  interfering  with  the  introduction  of  the  catheter.  Should 
a  polypoid  outgrowth  from  the  median  portion  of  the  prostate 
be  met  with  in  lithotomy,  it  should  be  cut  away  with  the  scissors 
or  a  probe-pointed  bistoury,  with  the  double  object  of  removing 

'  Paget,  Lect.  on  Snrg.  Path.,  3d  ed.,  p.  380  ;  and  Rattra}',  Trans.  Path.  Soc. 
Lond.,  vol.  xviii.  p.  188 
2  See  case  by  the  editor,  Trans.  Path.  Soc.  Philada.,  vol.  iv.  p.  153. 


416    TUMORS  AND  TUBERCLE  OF  THE  PROSTATE. 

the  obstacle  to  voluntary  micturition,  and  preventing  the  forma- 
tion of  a  new  concretion.  Sir  Henry  Thompson'  states  that  he 
has  twice  removed  such  a  tumor  successfully,  and  an  equally 
gratifying  result  was  obtained  by  Sir  James  Paget,^  who  refers 
to  two  additional  cases  in  other  hands.  If  the  existence  of  a 
valvular  outgrowth  of  the  middle  lobe  could  be  diagnosed,  it 
should  be  reached  by  incisions  similar  to  those  practised  in  the 
lateral  operation  for  stone. 

y.  Carcinomatous  Tumors. — Of  the  primary  cancerous  tumors, 
the  only  one  met  with  in  the  prostate  is  the  true  epithelial 
glandular  carcinoma,  due  to  proliferation  of  the  epithelial  ele- 
ments of  its  ducts  and  acini,  and  synonj-mous  with  the  adenoid 
carcinoma  of  Billroth,  as  found  in  other  glandular  organs.  It  is 
a  very  soft,  succulent,  vascular  growth,  and  is,  therefore,  to  be 
classed  among  the  medullary  or  encephaloid  formations.  Scir- 
rhus,  colloid,  and  melanosis  are  unknown. 

By  far  the  best  accounts  of  this  aflection  that  have  as  yet 
appeared,  are  those  of  Professor  Socin,^  Dr.  Oscar  Wyss,^  Dr. 
Jacques  Jolly,'  and  Sir  Henry  Thompson.^  All  of  these  writers, 
however,  have  included  in  their  descriptions  cases,  which,  from 
the  tender  age  of  the  subjects,  the  rapid  progress  of  the  disease, 
the  large  dimensions  of  the  tumor,  the  absence  of  lymphatic 
involvement  and  secondary  deposits,  and  confirmatory  micro- 
scopical evidence,  in  at  least  two  instances,  which  in  their 
macroscopical  characters  resembled  the  remainder,  should  be 
classed  among  the  sarcomas.  These  are  considered  sufficient 
reasons  for  their  exclusion,  and  for  drawing  the  following  clini- 
cal history  of  carcinoma  from  adult  cases,  with  lymphatic  in- 
volvement and  metastatic  deposits  in  other  organs.  The  cases, 
seventeen  in  number,  in  six  of  which,  minute  examination  dis- 
closed the  histological  peculiarities  of  carcinoma,  are  recorded 

'  Practical  Lithotomy  and  Lithotrily,  p.  126. 
2  Med.  Times  and  Gaz.,  vol.  ii.,  18o9,  p.  529. 

»  Hdbch.  d.  Allg.  u.  Spec.  Chir.,  1875,  Bd.  iii.  Abtli.  ii.  Lief  8,  2  Halfte,  p. 
105. 

*  Virchow's  Archiv,  Bd.  xxxv.,  1866,  p.  378. 

*  Archives  Generales  de  Medecine,  Ser.  vi.  t.  xiii.  pp.  577  aud  705,  and  t. 
xiv.  pp.  61  and  184. 

*  Op.  cit.  p.  258. 


TUMOES    OF    THE    PROSTATE.  417 

by  Langliaus,^  Tyson,^  Lebert,^  Guyon,*  Billroth,^  Tliompson," 
Laiig-staftV  Adams,*^  Waltoii,^  Simon,'"  Cock,"  Dalby,'^  Fergus- 
son,'^  Armitage,'*  and  Wyss.'^ 

Carcinoma  of  tbe  prostate  seldom  occurs  before  middle  age. 
The  youngest  subject  in  wliom  it  has  been  met  with  was  twenty- 
live  years  old  at  the  time  of  the  appearance  of  the  first  symp- 
toms, the  case  being  recorded  by  Billroth.  One  of  Mr.  Simon's 
patients  was  forty-one;  while  the  oldest  subject,  who  was  under 
the  care  of  Sir  William  Fergusson,  was  seventy-one  years  of  age 
when  the  disease  manifested  itself.  The  average  age,  however, 
is  fifty-seven  years  and  a  quarter,  agreeing  in  this  respect  with 
the  affection  as  it  is  met  with  in  the  bladder. 

The  exciting  causes  of  the  complaint  are  not  understood. 
Traumatism  does  not  appear  to  exert  any  influence  upon  its  pro- 
duction. It  generally  arises  spontaneously,  being  in  many  cases, 
doubtless,  engrafted  upon  the  previously  enlarged  organ,  and 
makes  considerable  progress  before  it  awakens  any  serious  symp- 
toms. 

The  neoplasm  usually  involves  the  entire  gland,  substituting 
its  parenchyma,  and  often  destroying  all  traces  of  its  proper 
structure.  In  about  one-third  of  all  cases,  it  is  confined  to  a 
limited  portion  of  the  organ,  as  the  right  or  left  lateral  lobe,  the 
base,  or  the  median  portion.  In  the  instance  recorded  by  Tyson, 
the  middle  lobe  was  converted  into  a  tumor  three  inches  in  diam- 
eter. In  whatever  portion  of  the  prostate  it  may  be  seated,  it 
generally  gives  rise  to  a  circumscribed,  well  defined,  more  or 
less  ovoidal,  even,  rarely  bosselated  or  lobulated,  mass,  which 
may  reach  the  dimensions  of  a  fist.  Firm  and  tense  in  its  earlier 
stages,  it  becomes   soft  and  elastic  with  age.     On  section,  it 

'  Hdbch.  cl.  AUg.  u.  Spec.  Chir.,  ut  supra,  p.  108. 

2  Proceedings  Path.  Soc.  Pliilada.,  vol.  iii.  p.  116. 

3  Vircliow's  Arcbiv,  Bd.  xxxv.  pp.  381  and  389. 
*  Arch.  Gen.  de  Med.,  t.  xiv.  p.  194. 

s  Chirurgische  KHnik.  Zurich,  1860-1867,  p.  343. 

K  Op.  cit.,  p.  269.  ^  Med.-Chir.  Trans.,  vol.  viii.  p.  279. 

8  Loudon  Lancet,  vol.  i.,  1853,  p.  394. 
8  Trans.  Path.  Soc.  London,  vol.  ii.  p.  287. 
'0  London  Lancet,  vol.  i.,  1850,  p.  291. 
"  Adams  on  the  Prostate,  2d  ed.  p.  147.        '^  Ibid. 

'3  London  Lancet,  vol.  i.,  1853,  p.  473.  '*  Thompson,  op.  cit.,  p.  270. 

"5  Virchow's  Archiv,  Bd.  xxxv.  p.  381,  and  case  26  of  table. 
27 


418    TUMORS  AXD  TUBERCLE  OF  THE  PROSTATE. 

almost  always  appears  iiiiiformlv  soft  and  white,  like  the  brain 
substance;  or  it  may  be  of  a  yellowish,  spongy  nature,  and  inter- 
spersed with  cysts.  In  either  case  a  milky  juice  exudes  on  pres- 
sure. Xow  and  then,  cavities,  occupied  by  soft,  friable  tissue, 
purulent  matter,  or  clotted  blood,  are  formed,  in  consequence  of 
partial  gangrene,  with  fatty  degeneration  of  the  transformed 
inland  cells,  and  rupture  of  the  delicate  vessels  of  the  stroma. 
Histologically  it  is  made  up  of  a  very  delicate  basis  of  connective 
tissue  and  capillaries,  inclosing  loculi,  which  are  packed  with 
small,  polygonal,  largely  nucleated  epithelial  elements.  In  some 
cases,  the  stroma  contains  an  abundance  of  smooth  muscular 
fibres,  and  the  alveoli  are  filled  with  large  cylindrical  cells.^ 

Instead  of  being  confined  to  the  prostate,  carcinomatous 
growths,  in  about  one-half  of  all  instances,  show  a  tendency  to 
perforate  its  investing  capsule,  and  invade  the  associated  organs. 
The  most  common  seat  of  the  secondary  tumors  is  the  trigone 
of  the  bladder,  either  in  the  form  of  numerous  discrete  nodules 
seated  beneath  the  mucous  membrane,  which  rarely  ulcerate,  or 
as  a  cauliflower  excrescence,  which  partially  fills  the  cavity  of 
the  viscus,  and  exhibits  a  great  tendency  to  break  down  and 
bleed.  Similar  projections  may  be  met  with  in  the  urethra,  as 
in  the  case  of  Socin,  in  which  the  pedunculated  mass  was  as 
large  as  a  small  walnut.  Xow  and  then,  nodules  are  found  be- 
neath the  corresponding  urethral  mucous  membrane,  Avhich,  by 
their  confluence  and  softening,  may  convert  that  canal  into  a 
ragged  excavation.  The  seminal  vesicles,  the  rectum,  and  ure- 
ters may  also  be  invaded  by  the  rapidly  proliferating  growth. 

Secondary  deposits  are  found  in  at  least  ninety  per  cent,  of  all 
cases.  The  structures  most  liable  to  sufler  in  this  way  are,  in 
the  order  here  mentioned,  the  pelvic,  lumbar,  inguinal,  and 
mesenteric  lymphatic  glands,  the  liver,  lungs,  pleura,  kidneys, 
and  spinal  canal.  The  implication  of  the  glands  of  the  groin  is 
not  only  of  anatomical  interest,  but  of  great  importance  in  a 
diagnostic  point  of  view.  In  several  cases  thrombosis  of  the 
iliac  vein  has  been  observed. 

In  addition  to  these  lesions,  wdiich  depend  exclusively  upon 
the  new  formation,  other  changes  are  met  with  in  the  urinary 

'  Consult  the  reports  of  Billroth,  Langhaus,  Guj'on,  Lebert,  Wj^ss,  aud  Ty 
sou. 


TUMORS    OF    THE    PEOSTATE.  419 

organs,  wliich  may  be  referred  to  the  mechanical  impediment  to 
free  micturition.  Of  tliese  the  most  common  are  hypertrophy 
and  dilatation  of  the  bladder,  and  inflammation,  suppuration, 
or  atrophy  of  the  kidneys,  and  hj^dronephrosis. 

The  early  symptoms  of  carcinoma  of  the  prostate  are,  as  would 
naturally  be  inferred,  those  of  obstruction.  Not  only  are  there, 
as  in  ordinary  hypertrophy  of  that  body,  frequent  and  difficult 
micturition,  retention  and  incontinence  of  urine,  but  pain  is 
superadded,  which  is  rarely  present  in  the  latter  affection.  The 
suffering  is  present  both  during  and  after  micturition,  and  is 
generally  referred  to  the  prostate  and  neck  of  the  bladder;  but 
it  is  also  felt  along  the  urethra,  especially  at  the  gland  of  the 
penis,  and  in  the  region  of  the  sacrum,  the  loins,  and  hypogas- 
trium,  and  it  even  radiates  down  the  thighs.  It  is  often  constant 
and  excruciating  in  its  nature,  and  is  increased  by  the  straining 
efforts  made  to  empty  the  bladder  and  the  rectum.  It  is  worthy 
of  remark  that  it  bears  no  direct  relation  to  an  open  condition 
of  the  tumor. 

Spontaneous  hemorrhage  is  not  so  prominent  a  sign  as  in  car- 
cinoma of  the  bladder,  as  it  only  occurs  in  about  one-half  of  all 
cases,  in  only  one-fourth  of  which,  however,  is  it  an  early  mani- 
festation of  the  disease.  It  is  equally  frequent  whether  the 
growth  is  ulcerated  or  not,  although  in  the  former  condition,  the 
loss  is  more  profuse  and  exhausting  than  in  the  latter,  in  which 
the  source  of  the  bleeding  appears  to  be  rupture  of  the  enlarged 
vessels  of  the  prostatic  urethra  and  neck  of  the  bladder,  during 
the  straining  efforts  to  void  the  urine.  In  exceptional  instances, 
the  hemorrhage  is  due  to  catheterism,  the  operation  itself  being 
frequently  painful  or  difficult,  if  not,  indeed,  impracticable. 

Additional  evidence  of  the  existence  of  the  disease  is  afforded 
by  the  finger  in  the  rectum,  through  which  the  enlarged,  but 
exceptionally  tender,  organ,  as  well  as  the  hypertrophied  pelvic 
glands,  may  be  detected.  In  the  case  recorded  by  Guy  on,  the 
patient  being  much  emaciated,  and  the  bladder  empty,  the  tumor 
could  be  distinguished  by  hypogastric  palpation ;  and  in  one, 
observed  by  Billroth,  it  formed  a  prominent  swelling  in  the 
perineum.  In  thin  subjects,  the  secondarily  involved  iliac  and 
lumbar  glands  may  be  felt  through  the  abdominal  walls.  The 
presence  of  indurated,  and  possibly  tender,  glands  in  one  or  both 
groins,  as  has  been  observed  by  Cock,  Armitage,  Lebert,  and 


420  TUMORS    AND    TL'BEECLE    OF    THE    PROSTATE. 

Guyon,  especially  if  they  progressively  augment  in  size,  is  a 
sign,  the  importance  of  which  can  scarcely  be  overlooked.  This 
symptom,  along  with  the  greater  suffering,  and  the  less  frequent 
occurrence  of  hemorrhage,  serves  to  distinguish  carcinoma  of  the 
prostate,  on  the  one  hand,  from  carcinoma  of  the  trigone  of  the 
bladder,  with  which  it  ma}^  be  confounded;  and,  on  the  other 
hand,  when  taken  in  connection  with  the  excessive  pain  and 
marked  cachexia,  from  senile  hypertrophy  of  the  prostate. 

During  the  later  stages  of  the  affection,  the  so-called  carci- 
nomatous cachexia  manifests  itself  by  the  sallow,  shrunken  feat- 
ures, the  anxious  and  suffering  expression  of  the  countenance, 
by  the  rapid  emaciation,  loss  of  strength,  frequent  pulse,  and 
night  sweats.  (Edema  of  the  scrotum  and  limbs,  from  throm- 
bosis of  the  iliac  or  femoral  veins,  may  also  add  to  the  patient's 
discomfort. 

The  duration  of  the  disease  varies  from  nine  months  to  ten 
years,  the  average  being  three  years  and  a  quarter.  In  general 
terms,  it  may  be  stated  that  the  older  the  patient,  the  longer  is 
life  preserved.  The  most  frequent  cause  of  death  is  exhaustion, 
favored  in  a  few  instances  by  hemorrhage.  In  some  cases,  coma, 
l)robably  from  uremic  poisoning,  terminates  the  scene.  In  one 
instance,  rapid  collapse  was  due  to  perforation  of  the  bladder 
and  peritonitis;  while, in  two,  there  Avas  extravasation  of  urine, 
respectively  from  sloughing  of  the  urethra  and  sloughing  of  the 
ureter. 

The  treatment  of  carcinoma  of  the  prostate  is  entirely  pallia- 
tive. All  that  can  be  done  is  to  relieve  pain,  support  the  strength, 
and  empty  the  bladder  with  the  soft  catheter  as  often  as  may  be 
required.  When  the  general  condition  of  the  patient  is  good, 
the  growth  of  the  tumor  is  slow,  and  there  is  no  reason  to  sus- 
pect lymphatic  involvement  or  secondary  deposits  in  the  viscera, 
it  becomes  a  question,  which  rests  entirely  with  the  judgment 
of  the  surgeon,  whether  life  may  be  prolonged  by  extirpation  of 
the  tumor.  Billroth'  removed  a  mass,  as  large  as  a  duck's  egg, 
along  with  a  portion  of  the  bladder,  from  a  man  of  thirty.  The 
wound  cicatrized,  but  the  disease  returned  in  eight  weeks,  and 
death  ensued  fourteen  months  after  the  operation.  Xussbaum,^ 
in  1866,  successfully  removed  the  rectum,  the  prostate,  and  base 

'  Cbirurgische  Kliiiik.  Zurich,  1860-67,  p.  342. 
^  Baier.  Aerztl.  Intelligenzblatt,  No.  44,  1869. 


TUMORS    OF    THE    PROSTATE.  421 

of  the  bladder,  all  of  which  were  invaded  by  carcinoma.  Up- 
Avards  of  two  years  afterwards  the  disease  returned,  and  the 
patient  soon  died,  after  repeated  attacks  of  hemorrhage.  De- 
marqnay^  has  also  extirpated  the  lower  portion  of  the  bowel,  the 
membranous  urethra,  the  prostate,  the  base  of  the  bladder,  and 
the  seminal  vesicles;  but  his  patient  died  of  purulent  infec- 
tion. In  a  second  case,^  he  removed  the  anterior  wall  of  the 
rectum  and  the  prostate  below  the  urethra,  and  the  man  re- 
mained well  after  the  lapse  of  two  years. 

s.  Sarcomatous  Tumors. — Of  the  malignant  diseases  of  the 
prostate,  the  onl}-  one  met  with,  besides  carcinoma,  is  sarcoma, 
the  clinical  history  and  physical  appearances  of  which  present 
some  points  of  resemblance  with  those  of  the  former  affection. 
Although  there  are  at  least  seven  cases  on  record  which  might 
properh-  be  included  in  this  class  of  morbid  growths,  as  the  ages 
of  the  patients  varied  from  twenty-three  to  forty-two  years,  and 
the  miiuite  examination,  when  made,  showed,  in  general  terms, 
mereh'  masses  of  cells  containing  large  nuclei,  they  will  have  to 
be  excluded,  as  they  are,  to  say  the  least,  of  doubtful  nature. 
Indeed,  the  only  authentic  case  of  sarcoma  in  an  adult,  confirmed 
by  minute  investigation,  is  that  reported  by  Socin,^  as  occurring 
in  a  man,  fifty-one  years  of  age,  who  had  been  troubled  with 
irritability  of  the  bladder  for  one  year,  and  with  retention  of 
urine,  which  demanded  the  constant  use  of  the  catheter,  for  six 
weeks  before  death  from  septicemia.  Section  disclosed,  as  re- 
presented in  fig.  121,  an  ovoidal  growth,  which  was  attached 
to  the  median  lobe  of  the  gland  by  a  delicate  pedicle,  which  had 
l)een  perforated  by  the  catheter.  The  base  of  the  tumor  was 
calcified ;  while  the  remainder  was  soft,  very  vascular,  and 
slightly  ulcerated.  The  microscope  disclosed  a  highly-  vascular 
round-celled  sarcoma.  A  few  mesenteric  glands  had  undergone 
the  same  degeneration.  The  bladder  was  hypertrophied,  and  it, 
as  well  as  the  ureters  and  pelves  of  the  kidne3'S,  was  dilated. 
The  remainder  of  the  prostate  was  not  involved,  but  its  gland- 
ular structure  was  enlarged. 

"With  the  foregoing  exception,  sarcoma  of  the  prostate  appears 
to  be  confined  to  infancy,  childhood,  and  early  boyhood.     Thus 

'  Gazette  Medicale  de  Paris,  1873,  p.  410. 

2  Ibid.,  p.  3S3.  3  Op.  cit.,  p.  109. 


422  TUMORS    AND    TUBERCLE    OF    THE    PROSTATE. 

of  eight  examples  recorded  by  Langhaiis,'  Bree,^  Stafford,' 
Langstaff,^  Solly ,^  Adams,^  Isambert/  and  Bush,^  tlie  respective 
ages  were  eight  months,  nine  months,  live,  eight,  three,  three, 
eight  and  a  half,  and  three  yeai*s,  the  average  being  four  years. 

Fi2.  121. 


Surcoma  of  the  Median  Portion  of  the  Prostate. 


Its  progress  is  remarkably  rapid,  tlie  duration  of  life  from  the 
appearance  of  the  fii-st  symptoms  to  the  fatal  termination  ranging 
from  three  to  seven  months,  or  four  months  on  an  average.  It 
differs  moreover  from  carcinoma  in  the  uniform  absence  of  lym- 
phatic involvement,  and  in  the  almost  universal  freedom  from 
secondary  deposits  in  distant  organs,  the  liver  alone  having 
been  affected  in  one  instance.  The  mass  attains  large  dimen- 
sions in  a  very  brief  period,  as,  for  example,  the  volume  of  a 
hen's  egg  in  three  months;  or  it  may  be  as  bulky  as  a  child's 


'  Op.  cit.,  p.  106. 

2  Provincial  Med.  and  Surg.  Journ.,  1846,  p.  76. 

3  Med.-Chir.  Trans.,  vol.  xxii.  p.  218.      ^ 
'  Thompson,  op.  cit.,  p.  276. 

'  Trans.  Path.  Soc.  London,  vol.  iii.  p.  130. 
6  Anat.  and  Dis.  of  the  Prostate  Gland,  2d  ed,,  p.  145. 
■  Bull,  de  la  Societe  Anat.  de  Paris,  IBog,  p.  57. 
^  Gross,  Urinary  Organs,  2d  ed.,  p.  719. 


TUMORS    OF    THE    PROSTATE.  423 

head,  and  fill  the  entire  pelvis,  as  in  the  case  of  the  infant  eight 
months  of  age. 

In  its  growth,  the  tumor  may  pursue  various  directions.  Thus, 
it  may  advance  forwards,  so  as  to  he  felt  in  the  perineum,  where 
it  may  be  mistaken  for  an  abscess,  and  be  punctured,  and  subse- 
quently protrude  as  a  fungous  mass  at  the  wound,  as  happened 
in  the  case  of  Langstatf.  In  other  examples,  it  makes  its  way 
through  the  sphincter  muscle  of  the  anus,  as  was  witnessed  by 
Bree.  It  may  also  grow  backwards  and  extend  as  high  up  as  the 
promontory  of  the  sacrum,  as  in  the  example  of  Langhaus  ;  or  it 
may  take  an  upward  course,  so  as  to  be  perceptible  above  the 
pubes,  as  in  the  instances  recorded  by  Solly  and  Isambert. 
Finally,  it  may  project  into  the  bladder,  as  in  the  case  of  Adams. 
In  its  earlier  stages,  little  evidence  of  its  existence  is  afforded 
by  rectal  palpation  ;  but  it  may  subsequentl}^  be  detected  in  this 
situation,  as  a  soft,  elastic,  lobulated  mass.  During  the  progress 
of  the  disease,  the  urethra  is  liable  to  alterations  in  its  form  and 
position ;  the  bladder  becomes  inflamed  and  thickened,  and  the 
kidneys  enlarge  or  suppurate. 

In  its  minute  and  gross  features,  sarcoma  of  the  prostate 
resembles  the  disease  as  it  occurs  elsewhere,  but  particularly  in 
the  testis.  The  specimen  of  Isambert  was  pronounced  by  Robin 
to  be  one  of  spindle-celled  tumor ;  while  that  of  Langhaus  was 
a  very  vascular  round-celled  sarcoma. 

The  symptoms  of  sarcoma  differ  somewhat  from  those  of  carci- 
noma of  the  prostate.  Dysuria  and  retention  of  urine  are  promi- 
nent signs,  the  latter  occurring  in  every  instance.  It  is  rather 
more  frequent  late  in  the  disease  than  as  an  early  manifestation ; 
and  almost  constantly  demands  the  employment  of  the  catheter, 
the  introduction  of  the  instrument  being  generally  difficult  and 
painful,  and,  in  many  cases,  impracticable,  thereby  necessitating 
a  resort  to  puncture  of  the  distended  bladder.  Essential  pain  is 
not  common.  Suffering  is  provoked,  however,  by  the  passage  of 
the  catheter,  the  insertion  of  the  finger  into  the  rectum,  and  by 
downward  pressure  above  the  pubes.  It  occasionally  occurs  be- 
fore, during,  and  after  micturition,  when  it  is  also  referred  to 
the  head  of  the  penis.  Hemorrhage  is  only  witnessed  after  in- 
strumental contact. 

The  diagnosis  is  based  upon  the  presence  of  a  soft,  rapidly- 
growing  tumor  in  front  of  the  rectum,  with  coincident  loss  of 


424    TUMORS  AXD  TUBERCLE  OF  THE  PROSTATE. 

flesli  and  streugtli.  Death  ensues  from  exhaustion  or  uremia ; 
although  in  tlie  case  of  Solly,  the  fatal  result  was  due  to  perito- 
nitis, for  which  there  was  no  assignable  cause. 

In  the  Avay  of  treatment,  all  that  can  be  done  is  to  relieve  pain 
by  anodynes,  to  draw  otf  the  urine  as  occasion  may  require,  or, 
if  catheterisra  be  impossible,  to  puncture  the  bladder,  and  to 
support  the  failing  powers  by  tonics,  stimulants,  and  nourishing 
diet. 

Sect.  II.— TUBERCLE  OP  THE  PROSTATE. 

The  prostate  is.occasionally  the  seat  of  tubercles.  The  affection, 
however,  is  extremely  rare,  and  is  ahnost  invariably  associated 
Avith  similar  deposits  in  other  organs  of  the  genito-urinary  appa- 
ratus, as  the  urethra,  bladder,  kidneys,  testicles,  and  seminal 
vesicles.  In  the  majority  of  cases  the  lungs  are  also  found  to 
be  invaded  by  tubercle.  In  a  case,  under  my  personal  observa- 
tion, it  coexisted  with  psoas  abscess.  The  patient  was  a  tall, 
slender  man,  twenty-seven  years  of  age,  for  the  last  four  of  which 
he  had  labored  under  spinal  disease,  from  the  immediate  effects 
of  which  he  finally  died.  The  tubercles,  eight  in  number,  and 
about  the  size  of  a  pea,  were  of  a  pale  yellowish  color,  of  a  soft, 
curd}'  consistence,  and  scattered  through  different  parts  of  the 
gland,  which  was  at  the  same  time  considerably  reduced  in  vol- 
ume. Strumous  matter  was  also  contained  in  the  seminal  vesi- 
cles, in  the  right  kidney,  and  ureter,  and  in  the  lymphatic 
glands  of  the  pelvis.     The  lungs  were  entirely  free  from  it. 

The  deposit  occurs  originally  in  the  form  of  gray,  miliary 
bodies,  which  are  developed  in  the  peritubular  connective  tissue. 
By  their  confluence,  and  by  the  progressive  formation  of  new 
tubercles,  they  lead  to  masses  as  large  as  a  pea,  or  even  a  chest- 
nut. These  subsequently  become  soft  and  chees}',  disintegrate, 
and  form  abscesses  of  variable  size  and  number.  In  the  instance 
reported  by  Lallemand,  there  were  not  less  than  thirty  small 
abscesses  of  this  nature.  In  other  examples,  there  is  onl}^  one 
sac,  which  is  capable  of  holding  several  ounces,  and  its  tendency 
is  to  evacuate  itself  into  the  urethra,  the  bladder,  the  rectum,  or 
even  into  the  peritoneal  cavity. 

The  volume  of  the  prostate  in  this  affection  is  usually  dimin- 
ished.    The  deposit  seldom  occurs  in  children ;  but  about  one- 


TUBERCLE  OF  THE  PROSTATE.  425 

half  of  the  cases  are  met  with  in  young  adults,  and  six  per  cent, 
in  individuals  after  the  seventieth  year. 

The  symptoms  are  not  characteristic,  being  merely  those  of 
chronic  prostatitis.  When  ulceration  or  abscess  occurs,  the  pro- 
gress and  termination  are  the  same  as  in  similar  affections  re- 
sulting from  ordinary  causes.  An  irritable  condition  of  the 
bladder,  purulent  urine,  hematuria,  a  tender  condition  of  the 
organ,  as  indicated  by  the  sound  and  by  rectal  touch,  along  with 
emaciation,  debility,  and  other  evidences  of  pulmonary  tubercu- 
losis, afford  presumptive  evidence  of  the  affection. 

When  the  character  of  the  disease  is  suspected,  recourse  is  had 
to  the  general  remedies  for  phthisis,  aided  bj^  counter-irritation 
to  the  perineum.  Instrumental  exploration  should  be  avoided, 
as'  it  not  only  aggravates  the  affection,  but  is  liable  to  lead  to 
acute  suppuration  and  other  evil  consequences.^ 

'  lu  an  emaciated  man,  sixty  years  of  age,  who  was  under  the  charge  of  the 
editor,  at  the  Philadelphia  Hospital,  during  the  past  winter,  an  attack  of  reten- 
tion of  urine  required  the  use  of  the  catheter.  Examination  with  a  No.  17  ex- 
ploratory bougie  had  imparted  to  the  touch  the  sensation  of  strictures  at  5^" 
and  6"  from  the  meatus.  He  was  seized  with  a  chill  in  twelve  hours,  whicli 
was  rapidly  followed  by  symptoms  of  acute  suppression  of  urine,  and  death  in 
forty-eight  liours.  Section  disclosed  numerous  miliary  tubercles  in  the  bulbous, 
membranous,  and  prostatic  portions  of  the  urethra,  with  similar  and  abundant 
deposits  in  the  enlarged  prostate.  The  bladder  was  in  a  condition  of  concentric 
hypertrophy  ;  but  its  muscular  fibres  were  completel}'  stripped  of  tlieir  mucous 
covering.  Both  kidneys  were  the  seat  of  cheesy  deposits  and  minute  abscesses. 
The  lungs  were  everywhere  pervaded  by  tubercles  and  cavities,  and  the  costal 
and  pulmonary  pleura?  were  extensively  adherent. 


CHAPTER  VI. 


CONCRETIONS  AND  CALCULI  OF  THE  PROSTATE. 

The  prostate,  like  other  glandular  organs,  is  liable  to  the  for- 
mation of  concretions  and  calculi,  which  often  become  a  source 
of  severe  suffering,  imperiously  demanding  surgical  interference. 
They  are  entirely  different,  both  in  their  structure  and  composi- 
tion, from  vesical  concretions,  and  appear  to  be  the  result  of 
disordered  follicular  secretion. 

Old  persons  are  most  prone  to  the  formation  of  small  concre- 
tions ;  and  there  are  few  examples  of  hypertrophied  prostate  in 
which  they  are  absent.  They  may,  however,  occur  at  any  period 
of  life,  save  early  boyhood ;  but  they  are  rarely  found  before  the 
twentieth  year.  In  their  number,  the  concretions  vary  from  a 
solitary  one  to  several  hundreds,  while  their  volume  rarely  ex- 
ceeds that  of  a  pin's  head.  Now  and  then  they  appear  as  large 
as  a  pea ;  but  in  this  event,  they  really  consist  of  numbers  of 
smaller  ones  united  by  mucus.  The  annexed  engraving,  from 
Marcet,  conveys  a  good  idea  of  the  size  and  form  of  these  little 
bodies.  They  exhibit  no  uniformity  in 
respect  to  their  color.  The  most  com- 
mon tints  are  brownish,  reddish,  amber, 
or  deep-yellow ;  and  their  consistence 
varies  from  that  of  suet  to  stone.  In 
their  structure,  they  are  usually  lami- 
nated. Marcet  and  other  chemists  long 
ago  ascertained  that  these  concretions 
consist  essentially  of  phosphate  of  lime 
and  organic  matter.  Iverson,'  who  has 
recently  made  a  quantitative  analysis, 
states  that  there  are  contained  in  100  parts  8  of  water,  15.80  of 
organic  matter,  37.64  of  lime,  2.38  of  magnesia,  1.76  of  soda, 
0.50  of  potassa,  33.77  of  phosphoric  acid,  and  0.15  of  insoluble 
material. 


Prostatic  Concretions. 


'  Maly's  Jaliresbericlit,  1875,  p.  358. 


CONCRETIONS    AND    CALCULI    OF    THE    PROSTATE.      427 

Prostatic  concretions  are  originally  formed  in  the  follicles  and 
ducts  of  the  organ,  as  represented  in  fig.  123  from  Socin,  from 
Avhich  they  escape,  in  whole  or  in  part,  being  visible,  on  dissec- 
tion, in  the  orifices  of  the  ducts,  or  just  beneath  the  mucovis 


Fig.  123. 


Two  Coaceatric  Coucretious  io  the  I'roslatic  Ducts. 


membrane  of  the  urethra,  or  in  the  parenchyma  of  the  prostate, 
into  which  they  have  intruded  by  ulcerative  absorption.  Micro- 
scopical concretions  are  normal  constituents  of  the  prostatic 
fluid,  even  in  young  lads,  their  number  increasing  with  the  age 
of  the  individual.  They  appear  to  arise  from  inspissation  of 
the  secretion,  by  the  separation  of  a  peculiar  organic  substance, 
and  probably  amyloid  transformation  of  the  epithelial  cells  of 
the  tubules  and  acini.  Their  tendency  is  to  set  up  irritation, 
causing  a  deposit  of  phosphates,  through  which  they  become 
more  dense  and  firm. 

When  their  number  is  considerable,  they  are  liable  to  break 
down  the  intervening  structures,  and  become  aggregated  together. 
In  this  way,  a  large  fibrous  cyst  is  sometimes  formed,  in  which 
the  concretions  lie  like  shot  in  a  bag.  A  single  sac  of  this  de- 
scription occasionally  contains  as  many  as  sixty,  or  even  several 


428      CONCRETIONS    AND    CALCULI    OF    THE    PROSTATE. 

liundrod  concretions,  from  the  dimensions  of  a  mustard  seed  to 
those  of  a  pea,  and  intermixed  with  thin,  glairy  mucus. 

By  the  coalescence  of  these  small  bodies,  and  the  further  de- 
position of  earthy  salts,  prostatic  calculi,  properly  so-called,  are 
formed,  which  have  been  shown  b}"  Lassaigne  to  consist  of  84.5 
parts  of  phosphate  of  lime,  0.5  of  carbonate  of  lime,  and  15  of 
animal  matter.  Their  composition  would  thus  seem  to  be  almost 
identical  with  that  of  salivary  calculi.  In  their  volume,  they 
rarely  exceed  the  size  of  a  pea;  but  they  have  been  found  of 
the  size  of  a  hazel-nut,  a  chestnut,  or  even  a  pullet's  egg.  In  a 
remarkable  case,  represented  in  tig.  124,  and  observed  by  Dr. 

Fis:.  124. 


Prostatic  ijitlc'uliis 


Barker,*  of  Bedford,  England,  the  calculus  weighed  three  ounces 
and  a  half,  and  consisted  of  twenty-nine  distinct  pieces,  of  a 
whitish  color,  and  porcelainous  lustre  and  hardness,  closely 
soldered  togetlier,  and  measuring  nearly  tive  inches  in  length, 
by  four  inches  and  five-eighths,  at  the  thickest  part.  It  was 
removed  from  a  man,  aged  twenty-six,  who  had  labored  under 
incontinence  of  urine  ever  since  his  fourth  year. 

Their  figure,  especially  when  the}-  are  solitary,  is  usually  more 
or  less  rounded ;  if,  however,  they  are  numerous,  they  are  apt 
to  be  polyhedral,  or  faceted;  in  some  instances,  they  are  flattened 
on  the  sides  like  a  grain  of  corn ;  now  and  then  they  are  elon- 
gated, pear-shaped,  conical,  cuboidal,  ramiform,  or  narrow  and 
constricted  at  the  middle,  like  an  hour-glass.  In  the  case  of  a 
young  man  of  twent}^,  I  found  them  of  a  regular  pj'ramidal 
figure.  When  there  is  only  one  concretion,  the  surface  is  gene- 
rally rough,  or  finelj-  tuberculated;  if,  on  the  contrary,  they  are 
numerous,  it  is  always  smooth  and  polished;  an  appearance  evi- 
dently produced  by  their  mutual  friction.  In  some  instances, 
the  calculi  are,  as  it  were,  articulated  together,  the  rounded  ex- 

'  Trans.  Prov.  Med.  and  Surg.  Assoc,  N.  S.,  vol.  iii.  p.  23o. 


CONCRETIONS    AND    CALCULI    OF    THE    PROSTATE.      429 

tremity  of  one  being  received  into  a  corresponding  concavity  of 
another.  Their  consistence  is  hard,  emitting,  when  struck  hy  a 
sonnd,  a  clear  ringing  note.  In  color,  they  are  white,  or  pale- 
brown,  their  interior  being  a  few  shades  lighter  than  the  surface. 

During  the  progress  of  their  development,  these  bodies  are 
liable  to  produce  absorption  of  the  surrounding  parts,  and  to 
change  their  situation.  Thus,  some  of  them  may  escape  entirely 
from  the  gland,  and  either  fall  into  the  bladder,  to  become  the 
nuclei,  perhaps,  of  a  corresponding  number  of  urinary  concre- 
tions, or  they  may  be  passed  with  the  urine.  Some,  again,  may 
become  impacted  in  the  orifices  of  the  excretor}^  ducts,  or  in  some 
abnormal  aperture,  and  project  upon  the  free  surface  of  the  ure- 
thra, either  at  its  prostatic  or  membranous  portion.  Lastly, 
when  they  are  situated  towards  the  back  part  of  the  gland,  they 
may,  hy  continued  ulcerative  absorption,  finally  escape  into  the 
connective  tissue  between  it  and  the  rectum,  making  their  way 
into  the  bowel  or  escaping  externally  through  an  abscess  in  the 
perineum. 

Calculi,  resembling  those  now  described,  are  occasionally  found 
in  the  ejaculatory  ducts,  which  traverse  the  prostate  from  behind 
forwards.  It  is  not  probable,  however,  that  they  are  of  the  same 
character ;  on  the  contrary,  it  is  more  reasonable  to  conclude  that 
they  are  derived  from  the  seminal  vesicles,  which,  as  is  well 
known,  are  sometimes,  although  rarely,  the  seat  of  a  peculiar 
form  of  concretion.  I  have  myself  seen  one  well-marked  example 
of  this,  in  a  young  man  of  twenty. 

There  is  no  uniformity  in  the  efi'ects  produced  by  these  bodies, 
either  upon  the  urinary  passages,  or  upon  the  system  at  large. 
When  small,  they  seldom  cause  much  uneasiness,  sometimes, 
indeed,  not  the  slightest,  and  it  is,  therefore,  not  surprising  that 
their  presence  should  often  be  overlooked  during  life.  This 
may  be  the  case,  even  when  they  exist  in  considerable  numbers. 
At  times,  however,  the}'  are  productive  of  great  inconvenience, 
if  not  of  excessive  suftering.  One  of  the  most  common  symptoms 
is  a  dull,  aching,  wandering  pain,  with  a  sense  of  uneasiness  in 
the  perineum  and  neck  of  the  bladder;  this  is  frequently  attended 
with  difficult  micturition,  and  is  liable  to  be  aggravated  when- 
ever there  is  the  most  trifling  derangement  of  the  general  health. 
During  the  progress  of  the  disease  the  bladder  becomes  highly 
irritable ;  there  is  a  constant  desire  to  urinate,  and  the  water  is 


430      CONCRETIONS    AND    CALCULI    OF    THE    PROSTATE. 

loaded  with  thick,  glairy  mucus,  very  much  as  in  catarrh.  Occa- 
sionully  the  concretions  encroach  so  much  upon  the  prostatic 
portion  of  the  urethra  as  to  give  rise  to  partial,  and  sometimes 
even  complete  retention  of  urine.  In  a  case  mentioned  by  Sir 
Astley  Cooper,'  the  calculi,  of  which  there  ^vas  an  immense 
number,  produced  not  only  painful  feelings  in  the  perineum,  but 
a  degree  of  irritation  which  kept  the  patient  in  a  state  of  con- 
tinual mental  excitement,  bordering  on  insanity.  The  suffering 
occasioned  by  these  bodies  is  usually  not  constant ;  on  the  con- 
trar}^,  after  having  persisted  for  some  time,  it  may  cease  alto- 
gether, or  recur  only  at  long  intervals. 

Little  need  be  said  respecting  the  general  symptoms  of  pros- 
tatic calculi,  as  they  do  not,  usually,  difl'er  materially  from  those 
which  accompany  stone  in  the  bladder.  The  health  frequently 
continues  good  for  many  years,  with  the  exception,  perhaps,  of 
an  occasional  paroxysm  of  fever,  loss  of  appetite,  and  disorder 
of  the  bow^els.  By  and  by,  however,  it  begins  to  decline,  and  at 
length,  after  years  of  suffering,  it  is  completely  shattered.  A 
young  man  of  twenty,  w^hom  I  attended  some  years  ago,  suffered 
as  severely  as  any  human  being  possibly  could  from  this  disease, 
under  which  he  had  labored  from  early  infancy.  He  was  literally 
reduced  to  a  skeleton,  and  had  not  strength  enough  to  walk  across 
his  room.  He  had  an  incessant  desire  to  void  his  water,  with 
excessive  scalding  and  burning  of  the  urethra,  and  was  constantly 
pulling  at  his  prepuce,  which  was  the  seat  of  a  most  distressing 
pain  and  itching.  I  sounded  him  repeatedly  without  detecting 
any  stone  in  the  bladder,  the  coats  of  w^hich  were  evidently  much 
thickened,  and  the  capacity  greatly  diminished.  In  the  prostatic 
portion  of  the  urethra  the  instrument  always  encountered  a  mass 
of  liard  substance,  emitting  a  distinct  noise,  and  easily  felt  by  a 
digital  exploration  of  the  rectum.  On  one  occasion  I  detached 
several  calculi,  wliich  w^ere  afterwards  excreted  with  the  urine, 
and  were  found  to  be  of  a  regular  pyramidal  shape,  smooth  and 
polished  on  the  surface,  of  a  dark  brownish  color,  and  of  the  size 
of  a  very  small  grain  of  corn.  The  patient  was  too  much  ex- 
liaustcd  to  justify  an  operation,  and  I  therefore  sent  him  home, 
where  he  soon  after  died.     His  body  was  not  examined. 

From  the  preceding  remarks  it  will  be  perceived  that  the 

'  Lectures  on  Surgery,  by  Tyrrell,  p.  331.     Phila.,  1835. 


CONCRETIONS    AND    CALCULI    OF    THE    PROSTATE.      431 

dia2:nosis  of  prostatic  calculi  is  by  no  means  always  easy.  The 
rational  symptoms  are,  in  truth,  of  little  account  in  the  determi- 
nation of  the  question  ;  for,  like  those  of  vesical  calculi,  they 
maybe  simulated  by  other  affections  in  so  embarrassing  a  degree 
as  to  render  them  utterly  worthless.  It  has  already  been  seen  that 
the  detection  of  these  bodies,  even  when  they  exist  in  consider- 
able numbers,  is  often  entirely  fortuitous.  They  are  particularly 
liable  to  be  overlooked  when  they  occur  in  union  with  urinary 
calculi,  stricture  of  the  urethra,  or  hypertrophy  of  the  prostate. 
When  bulky  or  numerous,  or  when  many  of  them  are  aggregated 
together,  and  lodged  in  a  large  cyst,  or  finally,  when  they  pro- 
ject, as  they  now  and  then  do,  upon  the  free  surface  of  the  ure- 
thra, or  into  the  bladder,  they  may  be  detected  by  a  digital 
examination  of  the  rectum,  and  the  introduction  of  a  sound, 
bougie,  or  catheter.  As  the  instrument  glides  along,  it  rubs 
against  the  foreign  body,  and  imparts  to  the  fingers  a  distinct 
grating  sensation.  If  it  consist  of  steel,  the  concretion  may  not 
only  be  felt,  but  it  will  be  apt,  if  struck,  to  yield  a  sharp,  metallic 
click,  similar  to  that  elicited  by  the  contact  of  the  sound  with  a 
urinary  calculus.  If  a  smooth  wax  bougie  be  used,  its  surface 
will  sometimes  be  rendered  rough  by  its  collision  with  the  ex- 
traneous body. 

When  the  finger  is  introduced  into  the  rectum,  the  prostate 
being  at  the  same  time  pressed  backwards  with  a  sound  or  silver 
catheter,  the  concretions  may  often  be  felt  as  so  many  hard, 
irregular  projections,  the  position  of  which  remains  unchanged 
by  any  force  that  can  be  a^jplied  to  them.  W^lien  a  considerable 
number  are  collected  together  in  a  nest,  they  give  the  finger  the 
feel  of  a  bag  of  marbles,  of  a  mass  of  clotted  blood,  or  of  a  bag 
of  air;  and,  if  struck  with  a  sound,  they  produce  a  sort  of  dull, 
jarring,  crepitating  noise.  Sometimes  a  concretion  of  this  kind 
is  discharged  along  with  the  urine,  when  a  careful  examination 
of  its  character  promptly  reveals  its  true  nature  and  origin.  In 
all  cases  of  doubt,  cliemical  tests  should  be  employed. 

Another  sign  upon  which  great  reliance  is  to  be  placed,  is  the 
circumstance  that  the  concretion  can  be  felt  only  in  one  particu- 
lar spot,  and  that  it  is  generally  immovably  fixed,  or  nearly  so. 
Whatever  posture  the  patient  may  assume,  the  situation  of  the 
foreign  body  remains  unaltered.  In  this  respect,  a  prostatic 
calculus  difiiers  remarkably  from  a  vesical  calculus,  which  is 


432   COXCRETIOXS  AXD  CALCULI  OF  THE  PROSTATE. 

liable  to  change  its  situation  not  only  with  every  variation  of 
posture,  but  also  according  to  the  state  of  repletion  and  vacuity 
of  the  bladder. 

Prostatic  calculi  are  usually  associated  with  disease  of  the 
urinary  apparatus,  as  stricture  of  the  urethra,  enlargement  of 
the  prostate,  stone  in  the  bladder,  hypertrophy  of  the  muscular 
coat  of  the  bladder,  and  organic  lesion  of  the  ureters  and  kid- 
neys. The  gland  in  which  they  are  situated  is  not  always 
hypertrophied ;  on  the  contrary,  it  is  sometimes  considerably 
wasted,  and  even  entirely  changed  in  its  substance,  being  con- 
verted into  a  thin,  fibrous  shell,  destitute,  in  great  degree,  of  the 
normal  structure.  Its  consistence,  in  this  affection,  may  be 
natural,  diminished,  or  augmented.  The  concretions  may  occur 
in  any  part  of  the  gland,  and  sometimes  they  are  scattered 
through  its  entire  substance.  Occasionally,  although  rarely,  they 
are  found  almost  exclusively  in  the  middle  lobe,  which  is  then 
in  a  state  of  hypertrophy.  A  single  calculus  sometimes  extends 
from  the  prostate  forward  into  the  membranous  portion  of  the 
urethra,  which  is  thus  often  dilated  many  times  bej'ond  its 
natural  caliber. 

In  the  treatment  of  prostatic  calculi,  not  much  is  to  be  ex- 
pected from  the  employment  of  internal  remedies,  beyond  the 
good  effects  which  they  may  exert  upon  the  general  health, 
which  must,  of  course,  always  receive  due  attention.  Any  com- 
plications that  may  exist  must  be  met  upon  general  principles  ; 
stricture  of  the  urethra  must  be  removed,  vesical  calculi  ex- 
tracted, morbid  sensibility  of  the  bladder  corrected,  the  bowels 
opened,  and  the  diet  regulated.  To  counteract  the  tendency  to 
phosphatic  deposits,  the  different  acids,  especially  the  nitric, 
must  be  put  in  requisition,  either  singly,  or  jointly  with  infusion 
of  uva  ursi  and  hops.     Alkalies  are  sometimes  indicated. 

The  radical  treatment,  which  is,  of  course,  purely  mechanical, 
must  be  regulated  by  circumstances.  When  the  calculus  projects 
into  the  urethra,  it  sometimes  admits  of  being  detached' with 
the  sound  or  catheter,  and  pushed  back  into  the  bladder,  from 
which,  if  it  be  not  too  bulky,  it  is  afterwards  discharged  along 
with  the  urine.  To  facilitate  the  separation  it  will  be  found 
useful  to  introduce  the  finger  into  the  rectum,  so  as  to  steady 
the  gland,  and  bring  it  thus  more  fully  within  reach  of  the  in- 
strument.    When  the  concretion  projects  from  the  gland,  but 


CONCRETIONS    AND    CALCULI    OF    THE    PROSTATE.      433 

is  firmly  fixed  in  its  substance,  an  attempt  may  be  made  to  seize 
and  extract  it  with  the  urethral  forceps,  or  cuvette,  employed 
upon  the  same  principle  as  in  calculus  of  the  urethra.  Civiale 
and  others  have  repeatedly  succeeded  in  dislodging  phosphatic 
concretions  with  the  litholabo,  first  detaching  them,  and  then 
removing  them  either  whole  or  piecemeal,  as  in  the  operation  of 
lithotrity. 

When  the  calculi  are  encysted,  or  contained  in  a  bag  in  the 
parenchymatous  substance,  the  only  wdy  in  which  the}'  can  be 
approached  is  to  cut  down  to  the  organ  upon  the  stafi:',  as  in  the 
ordinary  operation  of  lithotomy.  The  operation  is  not  difiicult ; 
nor  is  it  attended  or  followed  by  any  ill  efiects.  When  the  con- 
cretion is  of  large  size,  and  projects  forward  into  the  urethra,  so 
as  to  prevent  the  possibility  of  introducing  the  stafi:',  the  lateral 
operation  should  give  way  to  the  median,  as  was  long  ago  ad- 
vised by  Dionis.'  In  case  there  are  several  cysts,  situated  in 
dift'erent  parts  of  the  prostate,  a  corresponding  number  of  inci- 
sions may  be  required,  and  these  may  be  made  either  at  the  same 
or  at  dift'erent  periods.  Before  resorting  to  an  operation  of  such 
magnitude  and  importance,  the  surgeon  should  always  determine, 
if  possible,  the  precise  locality  of  the  foreign  bodies  ;  otherwise, 
after  he  has  made  the  necessary  incisions,  he  may  experience 
much  difficulty  in  finding  the  object  of  his  search,  or  be  greatly 
embarrassed,  if  not  completely  foiled,  in  his  attempts  at  extrac- 
tion. Occasionally  the  calculi  lie  in  the  connective  tissue 
between  tbe  prostate  and  the  rectum,  having  passed  thither  by 
ulcerative  absorption.  In  such  a  case,  instead  of  cutting  through 
the  perineum,  as  under  ordinary  circumstances,  I  should  prefer 
making  a  prerectal  curvilinear  incision. 

'  Operations  de  Cliirurgie,  par  La  Faye,  p.  231. 


28 


CHAPTER   VII. 
HEMORRHAGE  OF  THE  PROSTATE  GLAND. 

The  prostate  gland,  like  other  parts  of  the  hotly,  is  liahle  to 
hemorrhage,  varying  in  degree  from  a  few  drops  to  several 
ounces.  The  occurrence,  however,  is  extremely  rare,  and  is 
chiefly  met  with  in  aged  subjects,  in  consequence  of  the  forcible 
use  of  instruments,  leading  to  a  laceration  of  the  substance  of 
the  organ,  or  to  a  rupture  of  some  of  its  vessels,  which,  at  this 
period  of  life,  are  frequent!}'  in  a  state  of  enlargement  ancT  vari- 
cosity. Catheterism,  under  such  circumstances,  even  when  per- 
formed Avith  extreme  delicacy  and  gentleness,  is  liable  to  be 
followed  by  a  copious  flow  of  blood.  In  old  pei'sons  afl:ected 
with  hypertrophy  of  the  gland,  riding  on  horseback,  venereal 
indulgence,  a  fall  on  the  buttock,  or  a  blow  upon  the  perineum, 
will  occasionally  give  rise  to  this  form  of  hemorrhage,  which, 
although  generally  slight,  may  be  so  abundant  as  to  create  no 
little  uneasiness  for  the  patient's  safety.  A  smart  bleeding  of 
the  prostate  is  sometimes  produced  by  the  irritation  of  a  calculus, 
either  of  the  bladder,  or  lodged  in  its  own  substance.  The 
hemorrhage  is  occasionally  spontaneous,  and  then  probably  de- 
pends upon  ulceration  of  the  organ,  a  granular  condition  of  its 
surface,  or  the  presence  of  a  sarcomatous  or  carcinomatous 
tumor. 

Hemorrhage  of  the  prostate  is  generally  difiicult  of  recogni- 
tion, owing  to  its  liability  to  be  confounded  with  hemorrhage 
of  the  bladder  and  the  urethra.  When  the  blood  proceeds  from 
the  prostate,  a  portion  generally  escapes  in  a  pure  state,  free  from 
urine,  both  before  and  after  the  evacuation  of  the  bladder,  while 
tbat  which  passes  into  the  bladder  is  of  a  dark  muddy  appear- 
ance, and  is  voided  during  micturition.  These  phenomena, 
however,  are  not  characteristic,  and  it  is  only  by  coupling  with 
them  the  history  of  the  case  that  they  assume  a  diagnostic  value. 
Thus,  if  along  with  an  escape  of  blood  from  the  urethra  or 
bladder,  the  patient  is  conscious  of  having  received  an  injury 


HEMORRHAGE    OF    THE    PROSTATE    GLAND.  435 

either  bj  a  blow  on  the  perineum,  or  by  the  introduction  of  an 
instrument  in  the  region  of  the  prostate,  the  probability  is  that 
it  proceeds  from  this  gland,  and  not  from  the  urinarj^  passages, 
properly  so  termed.  When  the  hemorrhage  is  caused  by  an  ulcer 
of  the  prostate,  or  the  presence  of  a  tnmor,  the  circumstance  is, 
in  general,  easily  determined  l)y  the  sound  or  catheter. 

The  prognosis  of  this  variety  of  hemorrhage  is  favorable  or 
otherwise  according  as  it  is  simple  or  traumatic,  or  dependent 
upon  ulceration  of  the  gland,  or  the  presence  of  malignant  dis- 
ease. In  the  former  case,  it  is  generally  readily  amenable  to 
treatment,  and,  therefore,  free  from  danger;  in  the  latter,  it  is 
commonly  obstinate,  and  irremediable. 

The  treatment  of  hemorrhage  of  the  prostate  is  to  be  con- 
ducted upon  the  same  principles  as  that  of  hemorrhage  of  the 
urinary  passages  generally.  In  many  cases,  it  ceases  sponta- 
neously, or  readily  yields  to  rest  in  the  recumbent  posture,  cold 
applications  to  the  perineum,  and  iced,  acidulated  drinks. 
Where  these  means  fail,  or  where  the  bleeding  is  at  all  copious, 
recourse  is  to  be  had  to  the  exhibition  of  gallic  acid,  in  union 
with  opium,  every  two  or  three  hours,  in  the  proportion  of  two 
or  three  grains  of  the  former  to  half  a  grain  of  the  latter.  Few 
cases  resist  this  combination  beyond  ten  or  twelve  hours,  and  in 
many  instances  it  arrests  the  discharge  much  sooner.  When 
gallic  acid  fails  to  aiibrd  relief,  acetate  of  lead,  alum,  sulphuric 
acid,  spirit  of  turpentine,  ergotine,  and  the  tincture  of  the 
chloride  of  iron,  may  be  used  as  substitutes,  with  a  reasonable 
hope  of  success.  As  adjuvants,  cold  applications  to  the  anus, 
perineum,  and  the  hypogastric  region  should  not  be  neglected. 

Sometimes  marked  relief  has  followed  the  exhibition  of  Rus- 
pini's  styptic.  In  a  case  treated  by  Mr.  Brodie,'  in  which  a 
frightful  hemorrhage  was  connected  with  a  very  diseased  pros- 
tate, it  promptly  arrested  the  discharge  after  all  other  remedies 
had  failed. 

'  Brodie's  Select  Works,  p.  100.     Pliila.,  1847. 


CHAPTER   VIII. 

WOUNDS  OF  THE  PROSTATE. 

Wounds  of  the  prostate  are  the  result  either  of  accident  or 
design.  In  the  latter  case,  they  are  made  by  the  surgeon  with 
a  view  to  the  accomplishment  of  some  useful  purpose,  as  the 
extraction  of  a  stone  or  the  evacuation  of  the  urine.  However 
induced,  they  vary  in  extent  and  importance,  from  a  mere 
scratch,  as  it  were,  to  the  complete  division  of  the  organ.  In 
respect  to  their  character,  they  are  of  different  kinds,  as  incised, 
lacerated,  punctured,  and  gunshot,  as  in  other  parts  of  the  body. 

The  best  example  of  an  incised  wound  of  this  gland  is  that 
which  occurs  in  the  lateral  operation  of  lithotomy,  in  which  the 
organ  is  always  divided  on  one  side,  generally  the  left.  The 
extent  of  the  wound  varies  in  the  hands  of  different  surgeons, 
some  being  in  favor  of  a  small,  others  of  a  free  division.  The 
subject,  which  is  of  great  practical  importance,  has  been  dis- 
cussed elsewhere,  and  need  not,  therefore,  detain  us  here. 

Lacerated  wounds,  which  partake  also  of  a  punctured  nature, 
of  the  prostate  are  generally  produced  by  the  forcible  or  incau- 
tious use  of  instruments  in  attempting  to  draw  off  the  urine. 
An}^  portion  of  the  gland  may  suffer  in  this  way,  but  the  one 
which  is  most  liable  to  be  injured  is  the  middle  lobe,  which, 
from  its  size  and  situation,  often  forms  a  serious  obstacle  to  the 
evacuation  of  the  bladder,  and  therefore  is  most  commonly  per- 
forated by  the  catheter.  The  whole  gland  is  sometimes  acci- 
dentally bored,  if  such  an  expression  is  allowable,  in  this  manner, 
without  being  followed  by  any  serious  mischief,  much  less  by 
loss  of  life.  False  passages  of  the  prostate,  as  these  perforations 
may  be  appropriately  denominated,  are,  however,  sometimes 
dangerous  from  the  manner  in  which  they  interfere  w^ith  the 
neighboring  parts.  "When  they  penetrate  the  pelvic  fascia  they 
are  liable  to  be  followed  by  violent  inflammation  and  death.  A 
perforation  of  this  kind  sometimes  extends  into  the  rectum,  and 
leads  to  the  formation  of  a  fistule.     It  occasionally  happens  that 


WOUNDS    OF    THE    PROSTATE.  437 

tlie  passage  becomes  lined  by  a  false  membrane,  and  assists  in 
conducting  the  urine  into  the  urethra. 

Shot  wounds  of  the  prostate  are  exceedingly  rare.  They  are 
always  complicated  by  fracture  of  the  pelvic  bones,  or  by  injurj^ 
of  the  uretlira,  bladder,  penis,  rectum,  or  the  bloodvessels.  Of 
the  seven  cases  recorded  during  our  late  war,  three  recovered, 
but  the  subjects  suffered  either  from  a  constant  escape  of  urine 
through  the  wound,  or  from  urethro-rectal  fistule. 

The  most  prominent  effects  of  wounds  of  the  prostate  are : 
hemorrhage,  which,  however,  is  seldom  considerable;  inflamma- 
tion ;  infi^ltration  of  urine  and  sloughing ;  retention  of  urine 
from  tumefaction  of  the  affected  parts,  and  the  pressure  which 
they  exert  upon  the  lumen  of  the  prostatic  portion  of  the  ure- 
thra ;  urethro-rectal  fistules ;  and  abscess,  situated  either  in  the 
substance  of  the  organ,  or  between  the  gland  and  the  rectum. 

Wounds  of  the  prostate,  especially  when  unattended  by  lesion 
of  the  integuments,  must  necessarily  be  more  or  less  obscure  in 
their  character,  if  not  wholly  beyond  our  power  of  diagnosis.  This 
being  the  case,  little  need  be  said  on  the  subject  of  treatment, 
beyond  the  fact  that  this  should  be  conducted  upon  general 
principles.  From  the  great  liberty  which  we  may  take  with 
this  gland,  the  slight  pain  which  attends  its  injuries,  and  the 
little  sympathy  which  it  enjoys  with  the  rest  of  the  system,  or 
even  the  parts  with  which  it  is  more  immediately  associated,  it 
is  obvious  that  ordinary  wounds,  whether  incised,  lacerated, 
contused,  or  punctured,  are  generally  amenable  to  the  common 
antiphlogistic  means,  and  that  there  is  much  less  reason  to  dread 
them,  in  relation  to  inflammation  and  its  effects,  than  the  sur- 
rounding structures. 

Wounds  of  the  [)rostate  are  sometimes  attended  by  trouble- 
some hemorrhage,  especially  in  elderly  persons.  As  there  are  ' 
no  large  arterial  trunks  from  which  the  bleeding  can  proceed, 
it  is  not  improbable  that  it  emanates,  under  such  circumstances, 
from  the  prostatic  plexus  of  veins,  which  are  often  varicose  and 
much  increased  in  volume,  particularly  in  calculous  subjects,  or 
in  such  as  are  affected  with  excessive  enlargement  of  the  pros- 
tate. A  severe,  and  even  fatal  hemorrhage,  however,  might  be 
caused  by  the  division  of  an  anomalous  arterj',  which  occasion- 
ally passes  along  the  side  of  this  gland,  on  its  way  to  the  penis, 
and  which  has  been  cut,  in  one  instance,  at  least,  in  the  lateral 


438  WOUXDS    OF    TPIE    PROSTATE. 

operation  for  stone.  From  whatever  source  the  hemorrhage 
arises,  it  is  obvious  that  our  chief  reliance  for  arresting  it  must 
be  placed  upon  compression,  since  it  would  l)e  folly  to  attempt 
ligation.  The  manner  of  applying  compression  has  been  jiointed 
out  in  connection  with  the  operation  of  lithotomj',  and  need 
not,  therefore,  detain  us  here. 


CHAPTER   IX. 

MALFORMATIONS  OF  THE  PROSTATE. 

The  only  anomaly  of  tlie  prostate  Avbich  is  of  the  slightest 
practical  importance,  is  that  known  as  congenital  aberration,  or 
ectopia,  of  the  anterior  middle  lobe  or  commissure,  to  which 
attention  was  first  called,  in  1865,  by  Professor  Y.  Luschka,^  of 
Tubingen,  who  pointed  out  its  connection  with  fistule  of  the 
penis.  The  case  was  that  of  a  suicide,  nineteen  years  of  age,  on 
the  back  of  whose  penis,  near  the  pubes,  there  wfis  an  opening 
about  the  sixth  of  an  inch  in  diameter,  which  led  into  a  canal, 
three-fifths  of  an  inch  long,  and  lined  by  a  pale  red  mucous  mem- 
brane. On  laying  this  open,  four  excretory  ducts  were  brought 
into  view,  which  proceeded  from  an  ovoidal  gland,  about  one- 
fourth  of  an  inch  in  its  greatest  diameter,  reposing  on  the  albu- 
gineous  coat  of  the  cavernous  bodies,  four-fifths  of  an  inch  in 
front  of  their  angle  of  union.  The  posterior  extremity  of  the 
gland  was  continuous  with  the  detrusor  muscle  of  the  bladder 
through  a  long,  filamentous  tendon.  In  its  structure,  it  was 
homologous  with  the  tissues  of  the  normal  prostate,  each  lobe 
possessing  its  proper  excretory  duct,  several  of  which  contained 
microscopic  concentric  concretions. 

From  this  case  it  would  appear  that  some  congenital  fistules, 
at  least,  of  the  dorsum  of  the  penis,  must  be  regarded  as  examples 
of  ectopia  of  ducts  arising  from  an  accessory  prostate,  or  a  mis- 
placed portion  of  that  organ.  In  an  example  recorded  by  Pri- 
bram,2  the  opening,  which  was  seated  on  the  back  of  the  penis, 
an  inch  and  a  quarter  behind  the  gland,  gave  issue  to  a  few 
drops  of  prostatic  fluid,  during  ejaculation,  while  the  semen 
escaped  by  the  normal  urethra.  VerneuiP  has  reported  an  in- 
stance of  gonorrhoea  of  the  fistulous  track  in  the  same  situation; 

'  Vircliow's  Arcbiv,  Bd.  xxxiv.  p.  592. 

2  Prager  Vierteljalirschrift,  Bd.  iv.,  1867,  p.  44. 

»  Archives  Geuerales,  Ser.  vi.  t.  vii.,  1866,  p.  670. 


440  MALFORMATIONS    OF    THE    PROSTATE. 

and  ^larelial/  and  Picardat-  noticed  a  similar  plienomenon  in 
two  cases  in  which  the  urethra  and  fistulous  opening  presented 
the  appearance  of  a  double  meatus.  In  the  case  of  the  latter 
observer,  prostatic  fluid  "was  also  ejaculated  by  the  abnormal 
orifice. 

'  Bull,  dc  I'Acad.  de  Med.,  t.  xvii.,  1853,  p.  640. 
2  Quoted  by  Verncuil,  p.  GG3. 


I 


PART   III. 

DISEASES  AND  INJURIES  OF  THE  URETHRA. 


CHAPTER   I. 
FUNCTIONAL  DISORDERS  OF  THE  URETHRA. 

Sect.  L— MORBID  SENSIBILITY  OF  THE  URETHRA. 

Hyperesthesia  consists  mainly,  if  not  exclusivel}',  in  an  ex- 
altation of  the  natural  sensibility  of  the  mucous  membrane  of 
the  urethra,  similar  to  that  which  is  so  frequently  witnessed  in 
the  throat,  larynx,  urinary  bladder,  eye,  and  stomach.  Both 
sexes  are  liable  to  it,  but  it  is  much  more  common  in  men  than 
in  women.  It  occasionally  exists  at  a  very  early  period,  and  is 
not  unfrequently  associated  with  the  same  complaint  of  the 
bladder. 

It  is  not  always  easy,  or  even  possible,  to  ascertain  the  nature 
of  the  exciting  causes  of  this  afl'ection,  so  diversitied  are  they 
in  their  character.  In  tlie  male  it  is  often  dependent  upon  the 
effects  of  gonorrhcea  and  gleet,  contraction  of  the  meatus,  phi- 
mosis, stricture  of  the  urethra,  and  enlargement  of  the  prostate 
gland;  and,  in  both  sexes,  upon  derangement  of  the  bladder,  the 
kidne3-s,  ureters,  anus,  and  rectum.  Ascarides  and  other  worms, 
ulcers,  abscesses,  fistules,  hemorrhoids,  polyps,  and  malignant 
tumors  frequently  occasion  it.  Excessive  venery,  onanism,  and 
ungratified  sexual  desire  may  also  be  enumerated  as  so  many 
exciting  causes  of  the  complaint.  It  sometimes  attends  inflam- 
mation, ulceration,  and  other  disorders  of  the  uterus,  the  vagina, 
and  vulva.  Vascular  excrescences,  whether  situated  witliin  the 
canal,  or  clustered  around  the  external  meatus,  often  produce 
similar  effects.  Lesions  of  innervation,  dyspepsia,  and  morbid 
states  of  the  urine  may  not  only  induce  it,  but  maintain  it  for 
an  indefinite  period.     The  probability  is  that  certain  occupations 


442  FUNCTIONAL    DISORDERS    OF    THE    URETHRA. 

predispose  to  its  occurrence,  as  riding  on  horseback,  constant 
sitting;,  and  protracted  standing.  I  have  seen  a  number  of  cases 
of  this  kind  in  literary  and  hypochondriacal  persons.  Some- 
times the  origin  of  the  complaint  may  be  traced  to  the  habitual 
use  of  certain  articles  of  food  and  drink.  Inebriates  often  sutler 
in  this  Avay.  Of  all  the  causes,  however,  onanism  and  inordi- 
nate sexual  indulgence  are,  I  have  reason  to  believe,  the  most 
common. 

The  symptoms  of  this  affection  are  subject  to  great  diversity, 
both  as  it  respects  their  nature  and  degree.  In  the  more  simple 
forms,  there  is  merely  a  slight  exaltation  of  the  normal  sensi- 
bility of  the  mucous  membrane,  as  evidenced  by  a  sense  of  titil- 
lation,  slight  scalding  in  micturition,  and  a  feeling  of  soreness 
along  the  lower  surface  of  the  penis  during  erection  or  copula- 
tion. AVlien  the  affection  is  more  fulh'  developed,  the  local  dis- 
tress is  not  only  more  severe  but  more  constant  and  diffused,  often 
extending  to  the  surrounding  parts,  as  the  perineum  and  anus, 
the  groins,  the  pubes,  and  the  genital  organs,  which  are  not 
unfrequently,  in  this  event,  the  seat  of  dull,  heavy,  aching,  or  of 
sharp,  darting  pains,  similar  to  those  of  neural g^ia.  The  bladder 
is  also  liable  to  suffer,  sometimes  sympathetically,  and  at  other 
times  from  a  positive  extension  of  the  disease.  The  desire  to 
micturate  increases  in  frequency,  and  as  the  urine  flows  along  the 
afl:ected  surface  of  the  urethra  it  gives  rise  to  a  burning  or  scald- 
ing sensation.  Occasionally  the  symptoms  resemble  those  of  stone 
in  the  bladder.  When  the  disease  exists  in  this  aggravated  form, 
there  is  ahva^-s  marked  disorder  of  the  general  health ;  the  appe- 
tite is  deranged,  the  bowels  are  constipated,  the  countenance  is 
haggard  and  wobegone,  the  extremities  are  habitually  cold,  the 
body  is  easily  impressed  by  atmospheric  vicissitudes,  the  mind  is 
peevish  and  fretful,  and  the  slightest  indiscretion  in  eating  and 
drinking  is  sure  to  augment  the  local  distress.  Vague  and  in- 
definable sensations  are  experienced,  not  only  in  the  urethra  and 
in  the  rest  of  the  genito-urinary  apparatus,  but  in  other  regions 
and  organs,  and,  as  they  always  have  a  tendency  to  alarm  the 
patient  and  absorb  his  attention,  the}-  are  generally  a  source  of 
real  suffering.  When  the  posterior  portion  of  the  urethra  is  in- 
volved, seminal  emissions  are  apt  to  take  place,  and  there  is  also 
frequently  an  unusually  abundant  flow  of  prostatic  mucus.  When 
the  attection  is  associated  with  gleet,  there  will  commonly  be  a 


MORBID    SENSIBILITY    OF    THE    URETHRA.  443 

slight  pnriform  discharge,  or  an  aj^pearance  of  little  flakes  re- 
semhling  fragments  of  boiled  rice.  The  urine  is  variously  altered 
in  its  properties;  in  general  it  contains  an  undue  quantity  of 
mucus,  and  not  infrequently  it  exhibits  under  the  microscope 
dift'erent  deposits,  especially  oxalate  of  lime  and  phosphates. 

Hemorrhage  occasionally  attends  this  affection,  but  the  occur- 
rence, if  I  may  judge  from  my  own  observation,  is  infrequent; 
nor  is  the  loss  of  blood  at  any  time  abundant.  A  distinguished 
physician  of  Xorth  Carolina,  who  has  long  been  a  martyr  to  this 
complaint,  informs  me  that  he  has  had  repeated  attacks  of  this 
kind,  some  of  which  had  lasted  a  number  of  days,  before  they 
finally'  yielded  to  treatment.  lie  speaks  of  several  other  cases 
in  which  he  has  witnessed  the  same  phenomenon.  The  blood 
sometimes  comes  away  in  a  pure  state,  but  more  commonly  it  is 
mixed  with  the  urine,  to  which  it  serves  to  impart  a  dirty,  dingy, 
red  appearance,  which  vanishes  the  moment  the  hemorrhage 
ceases.  It  is  not  always  easy,  in  these  attacks,  to  determine  the 
seat  of  the  bleeding,  whether  it  is  in  the  urethra,  the  bladder, 
the  ureters,  or  the  kidneys,  as  the  diagnosis  is  generally  obscure, 
if  not  altogether  impracticable.  In  the  case  of  my  medical 
friend,  the  greatest  amount  of  distress  is  in  the  prostatic  portion 
of  the  urethra,  but  he  also  experiences  much  uneasiness  in  the 
bladder,  penis,  and  sacrolumbar  region,  where  there  is  often  a 
heav}',  burning,  or  dragging  sensation.  Sometimes,  his  whole 
spine  is  tender  ;  the  genital  organs  are  cold  and  numb ;  and  there 
is  often  a  feeling  in  the  rectum,  similar  to  what  might  be  sup- 
posed to  be  caused  by  the  presence  of  a  large  foreign  body.  His 
last  attack  of  hemorrhage  continued  thirty-six  hours,  and  was 
promptly  relieved  by  gallic  acid,  in  doses  of  three  grains,  repeated 
every  three  hours. 

The  best  mode  of  determining  the  precise  nature  of  this  dis- 
order is  the  introduction  of  the  catheter.  One  of  medium  size 
is  selected  and  is  passed  with  the  greatest  care  and  gentleness, 
otherwise  it  will  be  sure  to  excite  severe  pain  and  spasm.  Pro- 
ceeding in  this  manner,  the  operator  ascertains  both  the  extent 
and  the  degree  of  the  morbid  sensibility ;  whether  it  is  limited 
to  a  portion  of  the  canal,  or  whether  it  is  diffused  over  its  whole 
length  and  breadth;  whether  it  is  slight  or  severe;  and,  finally, 
whether  it  is  simple,  or  complicated  with  stricture  of  the  ure- 


k 


444         FUNCTIOXAL    DISORDERS    OF    THE    URETHRA. 

thra,  enlargement  of  the  prostate  gland,  or  disease  of  the  blad- 
der. 

To  form  a  correct  estimate  of  the  value  of  such  an  examina- 
tion, the  attendant  should  recollect  that  the  introduction  of  the 
catheter,  especially  if  performed  for  the  first  time,  may,  even  in 
the  healthy  state,  be  productive  of  considerable  uneasiness,  if 
not  of  positive  pain.  Sometimes,  indeed,  the  distress  is  so  great 
as  to  induce  swooning,  or,  at  all  events,  a  disposition  to  syncope, 
with  severe  prostration  of  the  vital  powers,  as  is  indicated  by 
the  feebleness  of  the  pulse,  the  pallor  of  the  face,  and  the  abun- 
dant sweats,  together,  perhaps,  with  the  occurrence  of  rigors. 
The  greatest  amount  of  sensibility,  in  the  normal  state,  com- 
monly exists  at  the  curve  of  the  urethra,  at  the  bulbo-membra- 
nous  portion;  a  good  deal  is  also  generally  found  just  behind 
the  head  of  the  penis;  and  occasionally  it  is  very  remarkable 
at  the  very  commencement  of  the  canal.  The  edges  of  the  meatus 
are  often  quite  sensitive,  especiall_y  when  the  orifice  is  unnatu- 
rall}'  small  and  tight.  The  sensibility  of  the  canal  is  greatest, 
other  things  being  equal,  in  infancy,  childhood,  and  adoles- 
cence, and  least  in  old  age. 

The  true  pathology  of  this  disease  is  not  accurately  determined. 
There  is  no  doubt  that  it  is  occasionally  caused  by  inflammation, 
either  subacute  or  chronic  in  its  character;  but  very  frequently 
it  exists  entirely  independently  of  this  lesion,  and  appears  to  be 
merely  an  exaltation  of  the  normal  sensibility  of  the  mucous 
membrane,  unaccompanied  even  by  the  slightest  congestion  of 
the  capillar^'  vessels. 

The  treatment  of  this  affection  cannot  ahvays  be  conducted 
upon  strictl}^  scientific  principles,  since,  as  already  stated,  it  is 
often  extremely  difficult  to  determine  its  true  character.  In  all 
cases,  it  is  a  matter  of  paramount  importance  to  inquire  into  the 
nature  of  the  exciting  cause,  and  the  existence  or  absence  of 
complications.  If  the  cause  be  appreciable,  or  still  in  operation, 
it  should,  if  possible,  be  removed,  otherwise  no  mode  of  manage- 
ment, however  energetic  or  judicious,  will  be  likely  to  afford 
any  permanent  benefit. 

In  general,  marked  relief  will  follow  the  use  of  antiphlogistics, 
especially  if  the  disease  be  attended  with  an  increased  discharge 
of  mucus,  of  puriform  matter,  or  of  pus,  as  will  be  apt  to  be  the 
case  when  it  has  arisen  from  stricture  of  the  urethra,  gonorrha^a, 


MORBID    SENSIBILITY    OF    THE    URETHRA.  445 

or  chronic  enlargement  of  the  prostate  gland.  The  bowels 
should  be  well  moved  with  mild  but  elRcient  purgatives ;  the 
diet  should  be  bland  and  restricted  ;  and  free  use  should  be  made 
of  the  antimonial  and  saline  mixture.  The  system  having  thus 
been  reduced,  the  disease  will  usually  promptly  disappear  under 
the  use  of  bicarbonate  of  soda,  either  alone  or  in  union  with 
uva  ursi  and  hop-tea,  mild  laxatives,  and  anodyne  injections, 
with  the  addition  of  a  small  quantity  of  Goulard's  extract. 
When  the  patient  is  dyspeptic,  or  of  a  broken-down  constitu- 
tion, a  course  of  blue  mass  and  ipecacuanha,  tonics,  and  a  gene- 
rous diet  may  be  necessary,  along  with  cold  bathing,  the  use  of 
alkalies,  and  exercise  in  the  open  air. 

The  introduction  of  a  full-sized  steel  bougie,  at  first  once,  and 
afterwards  twice  a  day,  is  sometimes  productive  of  the  l)est 
results.  Of  the  beneficial  effects  of  this  treatment  I  might,  if 
space  permitted,  adduce  numerous  cases.  The  pressure  which 
the  instrument  exerts  upon  the  walls  of  the  canal  soon  blunts 
their  sensibility"  and  often  acts  like  a  charm  in  dislodging  the 
disease.  In  this  way,  moreover,  the  afiected  surface  may  be 
directly  medicated,  by  anointing  the  instrument  with  various 
unguents,  especially  the  dilute  ointments  of  the  nitrate  of  mer- 
cury and  belladonna,  which  are  entitled  to  the  first  rank  in  the 
list  of  this  class  of  remedial  agents.  "When  the  morbid  sensi- 
bility is  connected  with  involuntary  seminal  emissions,  hardly 
anything  short  of  cauterization  of  the  prostatic  and  membranous 
portions  of  the  urethra  will  be  likely  to  succeed.  Sometimes, 
indeed,  it  is  necessary  to  cauterize  the  canal  in  its  whole  length. 
When  the  disease  proves  very  obstinate  and  intractable,  a  blister 
may  be  aiiplied  to  the  perineum,  or,  what  is  better,  along  the 
under  surface  of  the  urethra.  Few  cases  will  be  able  to  with- 
stand this  remedy.  Whatever  mode  of  treatment  be  adopted, 
the  patient  should  carefully  refrain  from  sexual  indulgence  and 
exercise  on  horseback;  nor  should  he  allow  himself  to  become 
too  easily  discouraged  if  our  efforts  to  relieve  him  are  not  speedily 
crowned  with  success. 

When  the  exciting  cause  of  the  complaint  is  not  appreciable, 
the  best  internal  remedy  is  the  bromide  of  potassium,  in  doses 
of  thirty  grains  every  eight  hours.  It  not  only  corrects  the 
acidity  of  the  urine,  but  seems  to  exert  a  sedative  im[tression 
upon  the  urethral  mucous  membrane. 


4-lG         FUNCTIONAL    DISORDERS    OF    THE    URETHRA. 

Sect.  II.— NEURALGIA  OF  THE  URETHRA. 

Neuralgia  of  the  urethra  occasiouall}^  exists  at  an  early  period 
of  life,  but  is  most  common  after  the  age  of  puberty,  in  young 
persons  of  a  nervous,  excitable  temperament.  It  is  much  moi'c 
frequent  in  males  than  in  females.  Its  origin  is  generally  ob- 
scure; sometimes  it  is  traceable  to  external  injury,  as  a  bruise, 
or  to  the  lodgment  of  a  calculus;  sometimes  it  manifestly 
depends  upon  onanism,  or  excessive  sexual  intercourse;  now 
and  then  it  follows  an  attack  of  gonorrhoea,  orchitis,  or  disorder 
of  the  bladder,  prostate,  ureter,  or  kidney.  In  the  southwest, 
where  this  affection  is  not  infrequent,  it  is  often  dependent  upon 
a  miasmatic  impregnation  of  the  system,  and  ma}',  therefore,  be 
said,  under  such  circumstances,  to  have  the  same  origin  as  inter- 
mittent fever.  In  the  female,  I  have  known  neuralgia  of  the 
urethra  to  be  connected  with  hysteria  and  dysmenorrhoea.  In 
many  cases,  the  disease  is  associated  with  neuralgia  of  other 
parts  of  the  body,  especially  of  the  head,  chest,  and  back. 

The  manner  in  which  this  disease  makes  its  appearance  is 
variable ;  being  sometimes  sudden  and  unexpected,  at  other  times 
gradual,  and  preceded  by  a  sense  of  fatigue,  soreness,  or  uneasi- 
ness in  the  affected  part.  The  pain  is  of  a  sharp,  pricking- 
character,  darting  about  in  different  directions  with  the  rapidity 
of  lightning;  it  often  remits  or  even  intermits  for  a  few  seconds, 
and  then  recurs  with  its  former  violence  ;  it  is  generally  attended 
with  considerable  soreness  of  the  urethra  and  penis,  a  frequent 
desire  to  micturate,  and  more  or  less  scalding  in  voiding  the 
urine.  Occasionally  the  disease  is  strictly  periodical  in  its 
attacks,  coming  on  at  a  particular  time  of  the  day,  lasting  an 
hour  or  two,  and  then  gradually  declining,  to  reappear  al:»out 
the  same  time  the  next  day.  In  some  cases,  it  assumes  the  ter- 
tian or  quartan  type.  Distinct  chilly  sensations  occasionally 
mark  its  access,  especially  when  it  is  of  miasmatic  origin.  The 
following  case,  one  of  many  that  have  occurred  in  my  practice, 
affords  a  good  idea  of  the  nature  of  this  affection. 

T.  C.  li.,  a  student  of  medicine,  twenty-six  years  of  age,  of 
temperate  habits,  and  good  constitution,  was  seized  on  the  12th 
of  January'  with  a  frequent  and  urgent  desire  to  micturate,  at- 
tended with  a  scalding  sensation  of  the  urethra,  which  was  at 
the  time  entirely  free  from  disease.     Indeed,  the  patient  had 


NEURALGIA  OF  THE  URETHRA.  447 

never  had  an  attack  of  gonon-lioea,  nor  was  he  conscious  that  the 
parts  had  ever  been  injured  in  any  way  whatever.  Altliough 
he  had  no  difficulty  in  emptying  his  bladder,  he  found  that 
voiding  his  urine  neither  relieved  the  desire  to  pass  this  fluid, 
nor  put  a  stop  to  the  pain,  which  was  of  a  darting,  pricking- 
character.  Being  in  good  health  in  other  respects,  he  supposed 
that  the  symptoms  would  soon  disappear,  and  therefore  con- 
tented himself  with  a  large  dose  of  paregoric,  under  the  influence 
of  which  he  passed  the  night  comfortably  enough.  In  the  morn- 
ing the  pain  was  gone  ;  but,  to  his  surprise,  it  returned  late  in 
the  afternoon,  and  from  that  time  on  it  assumed  a  periodical 
type,  recurring  regularly  about  the  same  hour  every  day.  Thus 
it  continued  for  a  week.  The  general  health,  in  the  meanwhile, 
a[)peared  to  be  excellent ;  the  appetite  was  good,  the  urine  re- 
tained its  normal  character,  and  all  the  functions  seemed  to  be 
well  executed.  Satisfied,  from  a  careful  examination  of  the  case, 
that  the  disease  was  neuralgia,  I  put  the  patient  at  once  upon  the 
use  of  quinine  and  arsenious  acid,  giving  him  four  grains  of  the 
former  with  the  tenth  of  a  grain  of  the  latter,  every  five  hours. 
At  bedtime  he  took  blue  mass  and  rhubarb  in  sufficient  quantity 
to  move  his  bowels.  Under  the  influence  of  this  treatment, 
aided  by  proper  diet,  the  disease  promptly  lost  its  periodical 
character,  and  became,  in  every  respect,  mitigated.  In  ten  days, 
the  patient  was  so  much  relieved  as  to  be  able  to  go  to  the  lecture- 
room,  having  still,  however,  a  slight  burning  sensation  in  the 
urethra.  Supposing  that  this  would  disappear  spontaneously, 
he  discontinued  his  medicine,  and  resumed  his  accustomed  mode 
of  living.  On  the  6th  of  February,  the  pain  returned  with  some 
severity,  but  not,  as  before,  in  regular  paroxysms.  The  same 
prescription,  witli  the  addition  of  the  sixteenth  of  a  grain  of 
strychnia,  was  ordered,  and  steadily  persisted  in  until  the  13th 
of  the  month,  when  all  the  symptoms  had  disappeared.  To 
guard  against  relapse,  the  use  of  the  medicine  was  resumed  in 
five  days,  and  continued  for  forty-eight  hours,  when  it  was 
finally  laid  aside:  the  cure  being  apparently  complete. 

Neuralgia  of  the  urethra  is  often  a  troublesome  and  obstinate, 
although  never  a  fatal,  disease.  I  have  known  it  to  continue  for 
years,  not  steadily  but  intermittingly,  and  finally  to  disappear 
quite  suddenly,  without  any  evident  cause,  or  without  any  par- 
ticular treatment.     The  disease  is  most  apt  to  prove  obstinate 


448        FUNCTIONAL    DISORDERS    OF    THE    URETHRA. 

when  it  coexists  with  neuralgia  of  other  parts  of  the  body,  when 
it  occurs  in  persons  of  a  nervous,  irritable  temperament,  or  when 
it  is  associated  with  oro-anic  lesion  of  the  genito-urinarv  appa- 
ratus, 

Tlie  treatment  is  to  be  conducted  upon  the  same  principles 
as  that  of  neuralgia  in  other  parts  of  the  body.  The  cause  is, 
if  possible,  removed;  after  which  recourse  is  had  to  quinine, 
arsenic,  strj-chnia,  ergotine,  and  aconite,  variously  combined, 
and  persistently  exhibited,  their  eflects  being  duly  Avatched,  both 
by  the  patient  and  his  attendant,  for  fear  of  overdosing.  When 
the  affection  is  of  a  purely  miasmatic  origin,  no  other  treatment 
is  generally  required;  a  few  days  suffice  to  mitigate  the  morbid 
action,  and  a  few  more  to  dispel  it.  In  rare  cases,  long  continu- 
ance of  treatment  is  necessary,  and,  in  all,  care  should  be  taken 
to  guard  against  relapse.  The  bowels  should  not  be  neglected ; 
the  diet  should  be  properly  regulated ;  and  the  patient  must 
avoid  exposure  to  cold  and  wet.  In  the  milder  forms  of  the 
disease,  quinine  alone  will  often  speedily  eft'ect  a  cure;  but,  in 
general,  I  combine  with  this  substance  some  or  all  of  the  articles 
above  mentioned.  In  obstinate  cases,  valerianate  of  iron  some- 
times succeeds  when  all  other  remedies  fail. 

Little  is  necessary  in  the  way  of  local  treatment.  During  the 
paroxysm,  the  penis  may  be  immersed  in  warm  water,  or 
fomented  with  hot  cloths,  impregnated  with  laudanum ;  or, 
better  still,  the  patient  may  use  a  hot  bath,  and  an  anodyne 
enema.  These  measures  are  particularly  indicated  when  the 
pain  extends  to  the  neck  of  the  bladder,  or  when  the  attack  is 
attended  with  a  frequent  desire  to  micturate,  a  sense  of  scalding 
along  the  uretl)ra,and  great  uneasiness  in  the  head  of  the  penis. 
The  application  of  veratria  and  belladonna  ointment  is  some- 
times of  service,  in  mitigating  the  local  distress  and  reestablish- 
ing healthy  action.  In  some  cases  I  have  witnessed  good  eft'ects, 
especially  in  cold  weather,  from  making  the  patient  constantly 
carry  his  penis  in  a  thick  flannel  stall,  to  protect  it  from  atmo- 
spheric vicissitudes,  which,  as  is  well  known,  exert  a  most  power- 
ful influence  over  neuralgic  diseases,  in  whatever  part  of.  the 
body  occurring.  The  organ  should  be  habitually  elevated,  and 
care  be  taken  that  the  pantaloons  do  not  exert  any  undue  pres- 
sure upon  it.  It  need  scarcely  be  said  that  all  sexual  excitement 
should  be  avoided. 


SPASM    OF    THE    UEETHRA.  449 

Sect.  III.— SPASM  OF  THE  URETHRA. 

Spasm  of  the  urethra  is  characterized  by  transient  signs  of 
obstruction  of  this  passage,  which,  in  the  interval  between  the 
attacks,  possesses  its  normal  degree  of  dilatability,  while  the 
stream  of  urine  retains  its  natural  size.  In  these  respects,  spas- 
modic stricture,  as  this  symptom  is  usually  termed,  difters  from 
the  permanent  or  organic  form  of  the  atfection,  in  which  the 
urethra  and  the  stream  of  urine  are  permanently  narrowed. 

Depending  as  it  does  upon  reflex  muscular  action,  spasm  of 
the  urethra  is  readily  excited  by  any  cause  which  acts  upon  the 
sensory  nerves  of  the  mucous  membrane,  through  which  the 
involuntary  and  voluntary  muscular  fibres  which  encircle  the 
canal  are  thrown  into  a  state  of  cramp,  in  the  same  manner  that 
the  muscles  which  move  a  joint  contract  in  certain  arthritic 
aifections.  Hence,  of  the  local  exciting  causes,  the  most  fruitful 
are  morbid  sensibility,  inflammation,  organic  stricture,  phimo 
sis,  venereal  excesses,  the  presence  of  a  calculus  or  other  foreign 
substance,  lacerations,  abrasions,  ulcers,  cutting  operations, 
cauterization,  the  passage  of  acrid  or  acid  urine,  especially  in 
gouty  or  rheumatic  subjects,  the  effects  of  cantharides,  turpen- 
tine, and  alcoholic  drinks,  and  long-continued  voluntary  reten- 
tion of  urine.  Of  the  general  causes,  or  those  which  are  inde- 
pendent of  a  sensitive  state  of  the  urethra,  or  of  an  altered 
condition  of  the  urine,  the  most  common  are  affections  of,  and 
operations  on,  the  anus,  rectum,  and  uterus,  derangements  of 
the  digestive  and  nervous  systems,  and  mental  emotion. 

The  symptoms  of  spasm  of  the  urethra  are  frequent,  difficult, 
and  painful  micturition;  diminution  in  the  size  of  the  stream 
of  urine,  which  is  voided  in  feeble  jets  or  hy  drops;  and  retention, 
when  the  attack  is  aggravated.  They  usually  come  on  suddenly 
and  in  quick  succession,  generally  from  exposure  to  cold,  or 
intemperance  in  drinking,  especialh'  if  the  canal  have  already 
been  in  an  irritable  condition,  and  they  are  liable  to  pass  off'  as 
rapidl}'  as  they  appeared.  When  the  mucous  membrane  of  the 
urethra,  however,  is  abnormally  sensitive,  the  attack  may  last  for 
many  days;  and,  in  this  event,  symptomatic  fever  declares  itself. 

The  transient  nature  of  the  attack,  taken  in  connection  with 
the  fact  that  there  is  neither  permanent  narrowing  of  the  ure- 
thra nor  diminution  in  the  size  of  the  stream  of  the  urine,  is 
2d 


4.)0  FUNCTIOXAL    DISORDERS    OF    THE    URETHRA. 

sufficient  to  distinguish  spasm  from  organic  stricture,  wliicli  is 
the  only  affection  with  which  it  is  liable  to  be  confounded. 

The  treatment  is  palliative  and  radical.  To  overcome  the 
spasm  nothing  is  usually  required  beyond  the  introduction  of  a 
full-sized  catheter.  As  soon  as  it  is  gently  pressed  against  the 
seat  of  the  obstruction,  which  is  generally  at  the  bulbo-membra- 
nous  junction,  the  consentaneous  action  of  the  muscles  is  restored, 
the  compressor  muscle  of  the  urethra  relaxing,  while  its  oppo- 
nent, the  detrusor  muscle  of  the  bladder,  contracts,  and  the 
urine  is  voided.  In  the  absence  of  the  catheter  the  most  reliable 
remedies  are  the  hot  bath  and  a  hypodermic  injection  of  morphia, 
or  twenty  grains  of  Dover's  powder. 

The  radical  treatment  is  based  upon  the  removal  of  the  excit- 
ing cause,  the  obtunding  of  the  sensibility  of  the  mucous  mem- 
brane of  the  urethra  by  the  passage  of  steel  bougies,  and  the 
employment  of  the  measures  referred  to  in  a  previous  section. 
The  bowels  must  be  kept  open;  the  diet  should  be  regulated,  all 
stimulating  and  acid  articles  of  food  and  drink  being  scrupu- 
lously avoided ;  the  functions  of  the  skin  be  properly  maintained ; 
and  sexual  intercourse  be  interdicted. 


CHAPTER    II. 

STRICTURE  OF  THE  URETHRA. 

By  the  term  stricture  is  understood  a  permanent  diminution 
and  loss  of  dilatability  of  the  lumen  of  the  urethra,  through 
which  there  is  a  corresponding  obstacle  to  the  pas.'^age  of  the 
urine  and  the  introduction  of  instruments. 

The  causes  of  stricture  may  be  conveniently  arranged  under 
two  heads,  the  traumatic  and  the  pathological.  Of  these,  the 
latter  are  b}-  far  the  more  common.  Tumors  and  excrescences  of 
the  urethra,  and  a  varicose  state  of  the  mucous  memln-aiieof  this 
canal,  cannot  give  rise  to  stricture,  properly  so  termed,  and 
should,  therefore,  be  excluded  from  the  list  of  exciting  causes. 

A^iolence  inflicted  upon  the  uretlira,  whether  from  without  or 
within,  may  excite  inflannnation,  and  develop  a  stricture.  A 
wound,  penetrating  the  canal,  may  be  attended  with  loss  of  sub- 
stance, or  fail  to  unite  evenly,  and  so  induce  the  disease.  Some 
of  the  very  worst  and  most  unmanageable  cases  that  I  liave  ever 
seen  were  thus  produced.  The  particular  kind  of  injury  is  gene- 
rally a  blow,  fall,  or  kick  upon  the  perineum,  eventuating  in  a 
laceration  of  the  lining  membrane,  or  of  this  membrane  and  the 
subjacent  tissues.  Sailors  not  infrequently  suffer  in  this  way,  by 
being  precipitated  from  the  rigging  of  a  vessel ;  and  I  have  seen 
several  instances  in  which  the  accident  was  produced  by  persons 
falling  from  a  considerabl(i  height  upon  the  round  of  a  chair.  A 
bad  stricture  occasionally  results  from  violence  inflicted  by  a 
catheter  or  bougie.  The  cicatrice  left  after  lithotomy,  especially 
when  the  operation  has  been  followed  by  severe  inflammation, 
and  a  calculus  permanentlj'  lodged  in  the  membranous  portion 
of  tlie  urethra,  have  sometimes  been  succeeded  by  obstinate  con- 
traction. 

Of  the  pathological  causes  of  stricture,  the  most  frequent,  un- 
questionably, is  gonorrhoea.  Whenever  tliis  disease  is  obstinate 
and  protracted,  or  the  attacks  are  frequently  re[ieated,  it  is  almost 
certain  to  be  followed  bva  considerable  efl'usion  of  inflammatory 


452  STRICTURE    OF    THE    URETHRA. 

new  material,  and  more  or  less  contraction  of  the  urethra. 
Judfino-  from  mv  own  experience,  I  am  convinced  that  at  least 
ninety  per  cent,  of  all  cases,  not  traumatic,  are  the  effect  of 
2;onorrha?a.  Urethritis  from  common  causes,  as  frequent  parox- 
ysms of  spasm  of  the  canal,  lithiasis,  strong  injections,  non-specific 
female  discharges,  excessive  or  prolonged  sexual  intercourse,  and 
masturbation,  are  also  cai)able  of  producing  the  affection. 

Finally,  stricture  is  occasionally  produced  by  the  cicatrization 
of  chancres.  Of  this  1  have  witnessed  several  very  obstinate  cases. 
The  obstruction,  when  thus  induced,  is  generally  situated  at  the 
anterior  extremity  of  the  urethra,  just  behind  the  external  orifice. 

The  more  simple  form  of  the  affection  depends  upon  a  hyper- 
plastic condition  of  the  parenchyma  or  connective  tissue  of  the 
mucous  membrane,  which,  in  the  early  stages,  is  swollen  and 
oedematous  from  the  accumulation  of  young  cells  and  albuminous 
fluid,  at  the  same  time  that  the  surface  is  covered  with  minute 
granulations,  which  pour  out  a  gleety  discharge.  As  the  infiam- 
mation  becomes  more  chronic,  the  fluid  exudation  is  absorbed, 
the  colls  are  converted  into  contractile  fibrous  tissue,  and  the 
granulations  disappear.  As  a  natural  sequence,  the  mucous 
membrane  loses  its  pinkish  color,  and  is  converted  into  a  non- 
vascular, pale,  or  grayisij,  thickened  band  of  cicatricial  tissue. 
In  a  more  advanced  stage,  the  inflammatory  new  material  infil- 
trates the  submucous  and  muscular  coats  of  the  urethra,  gluing 
them  together,  so  that  they  are  unable  to  expel  the  last  drops  of 
urine.  In  the  worst  class  of  cases,  in  addition  to  the  foregoing 
structures,  the  erectile  tissue  and  proper  fibrous  tunic  of  the 
urethra  are  invaded  by  the  exudation,  and  converted  into  a  thick, 
dense,  inelastic  mass,  the  tendency  of  which  is  to  contract  more 
and  more  the  longer  it  remains  unrelieved. 

Stricture  of  the  urethra  occurs  in  both  sexes,  and  at  all  periods 
of  life.  Men,  however,  are  far  more  prone  to  it  than  women,  and 
it  is  most  common  in  young  adults  and  middle-aged  subjects. 
It  is  occasionally  met  with  as  a  congenital  vice  at  or  near  the 
external  meatus.  I  have  witnessed  it  as  a  result  of  gonorrhcea 
in  a  lad  of  sixteen,  in  whom  the  symptoms  were  of  three  years' 
duration,  and  I  have  also  seen  the  traumatic  form  of  the  afl'ec- 
tion  in  a  child  of  eight. 

Stricture  presents  itself  in  various  forms  and  degrees.  Thus, 
it  may  be  simple  or  complicated,  common  or  traumatic,  partial 


STRICTURE    OF    THE    URETHRA.  453 

or  complete,  soft  or  callous,  dilatable  or  imdilatable,  non-sensitive 
or  irritable,  permeable  or  impermeable,  recent  or  old.  These 
terms  are  sufficiently  significant,  and  do  not,  therefore,  require 
any  special  explanation.  Much  diversity  prevails  in  relation  to 
its  locality,  number,  shajie,  consistence,  and  extent. 

'No  part  of  the  urethra,  except,  perhaps,  the  prostatic,  is  entire!}' 
exempt  from  this  affection.  The  results  of  ray  practice  lead  me 
to  infer  that  it  is  most  common,  first,  in  that  portion  of  the  ure- 
thra which  is  comprised  between  the  scrotum  and  the  head  of 
the  penis  ;  secondl}',  at  the  membranous  part  of  the  tul)e,  or  at 
the  junction  of  this  and  the  bulbous  part,  and,  lastly,  at  the 
anterior  extremity,  within  a  few  lines  of  the  meatus.  I  have 
never  seen  a  stricture  in  the  prostatic  portion  of  the  canal,  and, 
therefore,  conclude  that  it  must  be  exceedingl}'  rare  there,  if 
indeed  it  ever  exists.  I  have  repeatedly  met  with  it  near  the 
external  meatus. 

The  seat  of  this  disease  has  been  very  carefully  examined  by 
Sir  Henry  Thompson,'  who  has  availed  himself  of  the  advantages 
attbrded  by  the  various  public  collections  in  London,  Edinburgh, 
and  Paris.  The  number  of  specimens  inspected  was  270,  embrac- 
ing 320  distinct  strictures.  Of  these  215,  or  67  per  cent,  of  the 
entire  number,  were  situated  at  the  subpubic  curvature  and  its 
vicinity,  or  the  junction  of  the  membranous  and  spongy  portions, 
and  one  inch  of  the  canal  before,  and  three-quarters  of  an  inch 
behind  the  triangular  ligament;  51,  or  16  per  cent.,  in  the  centre 
of  the  spongy  portion;  and  54,  or  17  per  cent.,  at  the  exter- 
nal orifice,  and  within  two  inches  and  a  half  of  that  point. 
Sir  Henry  found  that  the  affection  was  most  frequent  in  the 
bulbous  part  of  the  spongy  portion,  and  least  frequent  of  all  at 
the  posterior  part  of  the  mendjranous  portion.  In  226  cases,  the 
stricture  was  single,  and  in  185  of  these  it  occupied  the  posterior 
region,  in  17  the  middle  region,  and  in  24  the  anterior  region. 
In  8  cases,  the  canal  was  obstructed  in  all  these  regions,  in  10  in 
the  first  and  second  only,  in  10  in  the  first  and  third  only,  and 
in  13  in  the  second  and  tliird  only.^ 

'  Pathology  and  Treatment  of  Stricture  of  the  Urethra,  2d  ed.,  p.  83.  Loudon, 
1858. 

2  It  would  be  exceedingly  diflicvxlt,  if  not  imi)Ossible,  judging  merely  from 
measurements  made  on  wet  specimens,  to  determine  the  most  common  locality 
of  stricture,  since  the  urethra  of  the  living  subject  is  at  least  one  inch  s-horter 


454  STRICTURE    OF    THE    URETHRA. 

Strictures  vary  nuich  as  to  their  number.  .  In  a  majority  of 
the  cases  that  have  fallen  under  nw  observation,  there  was  not 
more  than  one;  frequently,  liowever,  I  have  seen  two,  and  occa- 
sionally I  have  met  with  three  and  even  four.  The  latter 
number  is  rare;  but  it  is  sometimes  exceeded.  Thus,  John 
Hunter  saw  an  instance  of  six ;  Lallemand,  of  seven  ;  Colot,  ot 
eight;  Leroy,  of  eleven  ;  and  Otis,  of  fourteen.  When  the  stric- 
tures are  multiple,  they  may  be  in  close  proximity  with  each 
other,  or  separated  by  a  considerable  interval.  Ducamp  states 
that  when  there  are  several  coarctations,  the  most  extensive  one 
will  be  found  at  the  curve  of  the  urethra,  and  the  othere  between 
that  point  and  the  head  of  the  penis.  My  practice  has  not  fur- 
nished me  with  any  such  coincidence.^ 

than  when  it  is  removed  from  the  body  and  stretched  out  for  inspection.  With 
a  view  to  throw  some  light  on  this  point,  the  editor  lias  made  careful  examina- 
tions, •witli  the  exploratory  bulbous  bougie,  Avhicli  is  the  only  instrument  that 
can  be  relied  upon  for  this  purpose,  of  all  the  cases  that  have  come  under  his 
personal  care  within  the  past  twenty-two  mouths.  Of  173  strictures,  occurring 
in  100  living  subjects,  76,  or  43.93  per  cent.,  were  found  in  the  posterior  region 
above  described ;  48,  or  27. 74  per  cent.,  in  the  middle  region  ;  and  4i),  or  28. 32  per 
cent.,  in  the  anterior  region.  The  percentage  of  coarctations  in  the  curved 
portion  of  the  urethra  was,  therefore,  less,  and  in  the  straight  portion  of  the 
canal,  greater  than  that  obtained  by  Sir  Henry  Thompson  from  his  examinations 
of  morbid  specimens.  47  were  examples  of  one  stricture  only  ;  34  of  two  ;  15 
of  three  ;  3  of  four  ;  and  1  of  five  strictures. 

Strikingly  diiferent  results  were  derived  by  Professor  Otis*  from  the  measure- 
ments of  258  strictures  in  100  living  subjects.  The  disease  was  seated  in  the 
posterior  region  in  only  14,  or  5  per  cent.  ;  in  the  middle  region,  in  81,  or  31 
per  cent.  ;  while  in  1G3,  or  63  per  cent  ,  it  was  located  in  the  anterior  region. 
Hence,  the  combined  investigations  of  Dr.  Otis  and  the  editor,  which  comprise 
431  strictures,  occurring  in  200  cases,  demonstrate  that,  during  life,  20.88  per 
cent,  of  strictures  are  found  in  the  region  of  the  subpubic  curvature  ;  29.93  per 
cent,  in  the  centre  of  the  spongy  portion;  and  49.18  per  cent,  in  the  anterior 
two  inches  and  a  half  of  the  canal. 

'  Of  the  100  cases  recorded  by  the  editor  in  the  preceding  note,  47,  or  less 
than  one-half,  were  examples  of  solitary  stricture.  A  point  of  great  practical 
importance  in  connection  with  the  subject  of  the  raultiplicitj'  of  strictureSi  and 
one  to  which  he  desires  to  call  special  attention,  relates  to  coarctations  seated 
within  the  anterior  inch  of  the  urethra,  or  what  may  be  termed  its  glandular 
portion.  When  this  region  is  affected  it  may  be  accepted,  as  a  rule,  that  one  or 
more  strictures  will  be  detected  farther  bacii.  Thus,  he  found  36  strictures  in 
the  glandular  portion,  and,  of  these,  only  3,  or  8.33  per  cent.,  were  single; 
while  in  19  it  was  double  ;   in  11  triple  ;  in  2  quadruple  ;  and  in  1  quintuple. 


*  On  Stricture  of  the  Male  Urethra,  its  Radical  Cure.     Pamphlet,  New  York,  1875. 


STRICTURE    OF    THE    URETHRA, 


455 


Stricture  is  met  with  under  several  varieties  of  form.     One  of 
tlie  most  common  is  the  linear,  in  which   the  urethra  exhibits 
the   appearance  of   being   constricted  by  a  thread.     When   it 
embraces  the  entire  circumference  of  the  canal,  it 
forms  a  diaphragm,  or  septum,  perforated  at  its         Fig.  126. 
periphery,  or  at  its  centre,  as  in  tig.   125,  from      ^f^ 

Fis.  12o. 


Linear  Stricture. 

Holmes.     "When,  on  the  other  hand,  the  coarcta- 
tion is  only  partial,  it  assumes  the  ajipearance  of     Bridie  stricture. 
a  crescentic  fold  on  one  side  of  the  canal.     In  rare 
instances,  a  small,  narrow  band  is  stretched  across  the  passage, 
constituting  the  bridle  stricture,  of  which  fig.  126,  from  Holmes, 
affords  a  good  illustration.     These  isolated  bands  are  probably 
nothing  more  than  short  false  passages. 

Tlie  annular  stricture,  fig.  127,  from  one  of  my  preparations, 
is  usually  from  one-fourth  to  one-third  of  an  inch  in  extent,  and 
involves  the  tissues  to  a  greater  depth  than  the  preceding  form. 
In  a  remarkable  instance  which  I  Avitnessed  many  years  ago, 
nearly  the  entire  length  of  the  canal  from  one  extremity  to  the 
other  was  involved. 

The  indurated  annular  stricture  is  characterized,  as  the  term 
implies,  by  great  hardening,  the  new  tissue  substituting  nearly 
all,  if  not  all,  of  the  tunics  of  the  urethra.  The  contraction  is 
greatest  at  the  centre,  the  whole  presenting  an  hour-glass  appear- 
ance, as  in  fig.  128,  from  a  private  specimen. 

The  average  distance  of  the  most  posterior  stricture  from  the  external  meatus 
was  five  inches  and  five-eighths.  That  the  affection  was  not  due  to  spasmodic 
contraction  of  the  muscular  fibres  of  the  urethra  from  irritation  reflected  back 
from  the  anterior  stricture,  was  shown  b}-  the  fact  that  it  persisted  after  the  free 
division  of  the  latter,  and  imparted  the  sensation  of  a  well-defined  band  or  ring, 
over  which  the  exploratory  bougie  abruptly  jumped,  so  to  speak,  on  its  witli- 
drawal. 


456 


STRICTURE    OF    THE    URETHRA. 


Finally,  a  stricture  may  be  tortuous,  and  deviate  more  or  less 
from  the  axis  of  the  canal.  It  may  be  indurated  or  not,  and  is 
liable  to  present  serious  difficulty  in  the  passage  of  instruments. 


Fii?.  127. 


ri2:.  128. 


Annular  Stricture. 


Indurated  Annular  Stricture. 


The  degree  of  contraction  ranges  between  the  slightest  diminu- 
tion of  the  natural  size  to  almost  complete  obliteration.  When 
the  disease  has  reached  this  point,  the  urine  is  discharged  in 
drops,  and  the  bladder  is  never  entirely  empty.  Few  strictures, 
however  firm  and  narrow,  can  be  said  to  be  impermeable,  in  the 
true  acceptance  of  the  term.  As  long  as  a  stricture  admits  of 
the  discharge  of  urine,  it  cannot  be  considered  as  impermeable, 
although,  from  its  tortuous  course,  its  multiplicity,  or  the  hard, 
callous  condition  of  the  surrounding  tissues,  through  which  the 
natural  relations  of  the  canal  are  materially  changed,  it  may  be 
impassable  by  the  bougie,  sound,  or  catheter,  in  the  most  skilled 
hands.  Hence,  I  assert,  upon  the  testimony  of  personal  experi- 
ence, that  there  is  a  class  of  strictures,  the  result  of  ordinary 
causes,  which,  while  they  admit  of  the  passage  of  urine,  slowly 
and  imperfectly  it  may  be,  do  not  permit  the  introduction  of 
any  instrument,  however  small,  into  the  bladder. 

Strictures  which  are  impermeable  to  urine  are  verj^  uncommon  ; 
nevertheless  they  occasionally  occur,  and  I  have  met  with  them 
both  in  the  male  and  female,  although  only  once  in  the  latter. 
In  the  male  I  have  seen  at  least  four  cases,  which  I  can  now  re- 
call to  my  mind,  of  this  form  of  coarctation.  The  last  was  that 
of  a  young  gentleman,  aged  twenty-four,  who,  in  consequence  of 
an  obstruction  thus  produced,  became  the  subject  of  stone  in  the 


STRICTURE    OF    THE    URETHRA.  457 

bladder,  which  I  removed  by  the  lateral  section.  Two  fistulous 
apertures  existed  just  in  front  of  the  scrotum,  through  which 
every  drop  of  urine  was  evacuated.  The  stricture  was  of  a  firm, 
dense,  fibrous  consistence,  and  of  a  whitish  appearance,  ofteriuiJ- 
great  resistance  to  the  knife,  and  completely  obliterating  the 
urethra. 

The  contracted  part  may  be  soft  and  elastic,  or  hard  and  firm, 
according  to  the  duration  of  the  disease,  and  the  degree  of  trans- 
formation of  the  inflammatory  new  material,  upon  the  presence 
of  which  the  obstacle  depends.  Recent  strictures  are  generally 
soft  and  yielding,  on  which  account  they  are  frequently  described 
as  dilatable  strictures  ;  old  strictures,  on  the  contrarj',  are  usually 
callous,  tight,  and  resisting.  Exceptions  to  this  rule  are,  of 
course,  not  uncommon.  Thus,  I  have  known  a  stricture  acquire 
such  a  degree  of  firmness,  in  a  few  months,  as  to  render  it  im- 
possible to  pass  even  the  smallest  sized  bougie.  On  the  contrarj^, 
I  have  occasionally  met  with  an  ancient  stricture  which  readily 
and  permanently  yielded  to  the  process  of  dilatation  in  a  very 
few  days.  It  is  worthy  of  remark  that  the  consistence  of  a 
stricture,  especially  if  it  be  large,  is  seldom  uniform,  but  that  it 
varies  in  ditierent  parts  of  its  extent,  being,  perhaps,  quite  soft 
at  one  point,  hard  at  another,  and  almost  cartilaginous  at  a 
third. 

The  sj-mptoms  of  stricture,  considered  generally,  are  a  dis- 
charge of  thin,  gleety  matter  from  the  urethra ;  diminution  of 
the  stream  of  urine,  which  is  usually  spiral,  forked,  flattened,  or 
dribbling;  frequent,  slow,  and  difficult  micturition,  often  pre- 
ceded, accompanied,  or  followed  by  a  sense  of  scalding ;  loss  of 
power  of  expelling  the  last  drops  of  urine  ;  uneasiness  about  the 
loins, perineum,  and  anus  ;  pain  in  coition  ;  nocturnal  emissions; 
elongation  and  thickening  of  the  penis  ;  and  hardness  at  the  seat 
of  the  obstruction,  detectable  by  the  finger.  During  the  pro- 
gress of  the  disease,  the  patient  is  liable  to  be  troubled  witli 
swelling  of  the  testicle,  chordee,  hemorrhoids,  hernia,  and  reten- 
tion or  incontinence  of  urine.  The  general  health  is  variously 
affected  ;  sometimes  slightly,  at  other  times  severely.  In  the 
more  aggravated  forms  of  the  malady,  there  is  almost  always 
derangement  of  the  digestive  organs  ;  the  system  is  more  or  less 
irritable ;  and  the  slightest  exposure,  fatigue,  intcm[ierance,  or 


458  STRICTURE    OF    THE    URETHRA. 

irreo:ularity  in  eating,  is  apt  to  be  followed  by  an  exacerbation 
of  the  local  suffering. 

One  of  the  first  circumstances  -which  generally  attracts  the 
attention  of  the  patient,  is  a  gleety  discharge  from  the  urethra. 
This  symptom  is  of  frequent  occurrence,  and  is,  in  fact,  some- 
times the  only  one  present ;  still  it  is  not  characteristic.  The 
fluid,  which  is  mucous,  or  muco-pnrulent,  is  more  or  less  opaque, 
thin,  and  viscid,  and  varies  in  quantity  from  a  few  drops  to  half 
a  drachm  or  more  in  the  twenty-four  hours.  It  is  usually  most 
abundant  in  the  morning,  before  micturition ;  stains  the  patient's 
linen,  and  agglutinates  the  lips  of  the  orilice  of  the  urethra.  The 
discharge  has  sometimes  a  thready  appearance,  like  vermicelli; 
and  not  infrequently  it  occurs  in  the  form  of  little  flakes,  of  a 
whitish  or  yellow  color,  similar  to  particles  of  soft-boiled  rice. 
The  secretion,  in  whatever  aspect  it  exhibits  itself,  proceeds  from 
the  mucous  membrane  of  the  urethra,  which,  in  most  cases  of 
stricture,  is  in  a  state  of  inflammation,  both  behind  and  in  front 
of  the  site  of  the  obstruction.  It  is  sometimes  absent  for  days 
together,  and  then,  in  consequence  of  increased  local  irritation, 
returns  as  copiously  as  ever.  Trifling  as  this  symptom  apparently 
is,  it  always  proves  a  source  of  great  annoyance  to  the  patient, 
who  looks  for  it  fifty  times  a  day,  and  is  sure,  when  he  finds  it, 
to  post  ott'  to  consult  his  physician  about  it. 

Another  early  symptom  is  a  slight  diminution  of  the  stream 
of  urine,  accompanied  by  a  sense  of  scalding  or  pricking  in  the 
urethra,  a  feeling  of  weiglit  at  the  neck  of  the  bladder,  and  an 
increased  frequency  of  micturition.  The  patient  is,  perhaps, 
obliged  to  use  the  chamber  several  times  during  the  night ;  and, 
if  he  is  exposed  to  cold,  takes  much  exercise,  or  indulges  a  little 
more  than  usual  in  the  pleasures  of  the  table,  he  finds  that  he  is 
unable  to  retain  his  water  as  well  as  formerly,  or  that  it  passes 
only  drop  by  drop,  and  with  considerable  pain  and  spasm.  By 
and  by,  the  local  symptoms  assume  a  more  decisive  character. 
The  stream  of  urine  is  much  smaller  than  it  was  at  first,  and  has 
a yyiry,  twisted,  spiral,  or  corkscrew  shape :  sometimes  it  is  double, 
forked,  or  bifurcated.  Its  force  is  also  sensibly  lessened  ;  instead 
of  being  projected  in  an  arched  form,  as  it  is  in  the  natural  state, 
to  a  distance  of  several  feet,  it  falls  perpendicularly  between  the 
patient's  legs,  or  upon  his  trowsers,  although  he  is  conscious  that 
the  bladder  at  the  time  is  making  unusual  efforts  to  expel  its 


STRICTURE    OF    THE    URETHRA.  459 

contents.  In  tlie  worst  forms  of  the  disease,  the  urine  is  dis- 
charged in  drops,  or  it  dribbles  away  from  the  penis,  and  flows 
noiselessh"  into  the  receiver.  This  mode  of  micturition  mia}'  be 
constant  or  intermittent,  and  is  often,  from  the  most  tritling 
cause,  followed  by  complete  retention. 

A  prominent  symptom  of  stricture  is  frequent,  slow,  and  diffi- 
cult micturition.  In  the  healthy  state,  the  moment  the  bladder 
contracts,  its  contents  begin  to  flow,  nor  do  they  cease  until  they 
are  completely  evacuated.  In  stricture,  on  the  contrary,  great 
difiiculty  is  often  experienced  in  starting  the  urine,  and  an  un- 
usual length  of  time  is  required  to  effect  its  discharge,  accom- 
panied by  much  straining,  and  pulling  of  the  penis.  In  fact,  the 
att'ected  part  is  obliged  to  undergo  a  sort  of  preliminary  dilata- 
tion, which,  as  well  as  the  subsequent  steps  of  the  process, 
demands  the  full  play  and  cooperation  of  the  diaphragm  and 
the  abdominal  muscles.  Straining,  sometimes  violent  and  long 
continued,  is  seldom  entirely  absent  in  this  disease.  To  promote 
the  flow  of  urine,  the  patient  throws  his  body  forwards,  and 
squeezes  with  all  his  might,  as  if  he  were  about  to  force  out  both 
the  bladder  and  bowels. 

In  nearly  all  cases  there  is  morbid  sensibility  of  the  urethra, 
or  of  the  urethra  and  the  neck  of  the  bladder.  The  atiection  is 
evidently  seated  in  the  mucous  lining  of  the  part,  and  often  con- 
stitutes a  source  of  real  suftering.  Considerable  diversity  obtains 
in  regard  to  the  nature  and  amount  of  this  morbid  sensibility. 
Most  commonly  it  is  a  scalding  or  burning ;  but  sometimes  it  is 
merely  a  feeling  of  soreness,  uneasiness,  or  tickling.  It  may  be 
circumscribed  or  ditiused  ;  slight  or  severe  ;  intermittent  or  per- 
sistent. The  most  trifling  circumstance,  such  as  an  acrid  state 
of  the  urine,  an  attack  of  rheumatism,  exposure  to  cold,  or  the 
use  of  stimulating  food  or  drink,  is  liable  to  increase  it. 

Patients  affected  with  stricture  sutter  much  with  pain  and 
tenderness  in  the  perineum,  anus,  and  penis.  Very  frequently, 
the  irritation,  which  is  always  purely  reflex,  extends  to  the 
groin,  the  inner  side  of  the  thighs,  the  sacrolumbar  region,  the 
gland  of  the  penis,  and  the  testes,  the  latter  of  which  are  occa- 
sionally so  exquisitely  sensitive  as  to  be  unable  to  bear  the 
slightest  pressure,  or  even  the  touch  of  the  finger.  The  bliidder 
also  is  often  the  seat  of  considerable  pain,  of  a  scalding  or  burn- 
ing character,  and  chiefly  referable  to  the  neck  of  the  organ, 


4(30  STRICTURE    OF    THE    URETHRA. 

altliougli  sometimes  it  is  diffused  over  the  entire  visciis,  and  is 
much  increased  by  pressure  upon  the  liypogastrium,  rough  exer- 
cise, sexual  intercourse,  and  other  causes.  A  most  distressing 
symptom,  occasionally  witnessed  in  this  complaint,  is  a  constant 
irritation  in  the  superior  part  of  the  rectum.  It  is  most  apt  to 
manifest  itself  when  the  disease  extends  its  ravages  to  the  pros- 
tate o-land  and  the  connective  tissue  between  the  bladder  and 
the  bowel. 

The  subjects  of  stricture,  especially  that  variety  which  is 
attended  with  hyperoesthesia  of  the  urethra  and  neck  of  the 
bladder,  are  very  prone  to  suffer  from  despondency,  nervousness, 
and  sexual  hypochondriasis,  in  consequence  of  imperfect  erec- 
tions, premature  ejaculation,  and  nocturnal  emissions,  which 
generally  take  place  under  the  influence  of  a  lascivious  dream, 
and  are  almost  always  accompanied  by  considerable  pain.  The 
semen,  at  such  times,  as  well  as  in  the  act  of  coition,  instead  of 
being  ejaculated,  passes  backwards  into  the  bladder,  or  is  re- 
tained in  the  urethra,  behind  the  obstruction,  from  which  it 
afterwards  oozes  out  by  degress,  or  is  discharged,  along  with 
the  urine,  in  a  state  of  solution.  It  is  for  this  reason  that  a 
man,  affected  with  a  tight,  callous  stricture,  is  sometimes  im- 
potent; for,  although  he  maybe  able  to  copulate,  he  cannot 
procreate,  because  none  of  the  secretion  reaches  its  destination, 
except,  perhaps,  when  the  act  is  unduly  protracted. 

Tlie  penis,  in  stricture,  undergoes  a  sort  of  hypertrophy  ;  it  is 
longer  and  thicker  than  usual,  more  or  less  deformed,  and  de- 
prived, at  least  in  some  degree,  of  its  natural  sensibility.  The 
prepuce,  which  generally  [)articipates  in  the  enlargement,  is 
sometimes  so  much  infiltrated  with  serum  as  to  require  to  be 
punctured,  in  order  to  prevent  gangrene.  These  appearances 
are  caused  by  the  constant  pressure  and  pulling  which  the 
patient  is  obliged  to  exert  to  facilitate  the  process  of  micturition. 

There  is  often  a  good  deal  of  hardness  of  the  urethra,  not  in 
its  entire  extent,  but  at  some  particular  point.  The  parts  most 
commonly  imi^licated,  according  to  my  observation,  are  the 
bulbous  and  membranous,  where  the  deposit  of  lymph,  the  im- 
mediate cause  of  this  symptom,  is  sometimes  so  considerable  as 
to  compress  the  canal,  or  throw  it  out  of  its  natural  course,  thus 
greatly  increasing   the  difficulty  of  introducing  a  catheter  or 


STRICTUEE    OF    THE    URETHRA.  461 

bougie.  The  induration,  which  is  always  produced  hj  an  exten- 
sion of  the  inliammation  of  the  mucous  membrane  of  the  urethra 
to  the  subjacent  tissues,  is  generally  easily  detected  by  the  ap- 
plication of  the  finger,  and  should  not  be  confounded  with  that 
which  is  caused  by  the  stricture  itself. 

Chordee  is  frequently  a  troublesome  symptom  in  this  disease. 
Although  most  common  at  night,  it  sometimes  comes  on  in  the 
day,  and  always  proves  a  source  of  much  annoyance,  if  not  of 
actual  sufi'ering.  When  the  cells  of  the  spongy  structure  of  the 
urethra  are  distended  with  lymph,  the  penis  in  erection  may  be 
drawn  downwards,  upwards,  or  laterally,  according  to  the  situa- 
tion of  the  effusion,  upon  the  presence  of  which  the  incurvation 
depends. 

Another  symptom,  which  is  occasionally  noticed  in  this  aifec- 
tion,  is  hematuria,  or  a  discharge  of  blood  from  the  urethra. 
The  hemorrhage  is  usually  slight,  and  seems  to  be  most  common 
in  old,  callous  strictures,  attended  with  dilatation  of  the  canal, 
and  varicosity  of  the  lining  membrane.  The  occurrence  is  most 
frequent  during  erections,  and  probably  always  depends  upon  a 
laceration  of  some  of  the  larger  vessels  of  the  affected  part,  which 
are  unduly  stretched  when  the  penis  is  in  this  condition.  A 
considerable  hemorrhage  is  also  sometimes  excited  during  the 
passage  of  a  bougie  or  catheter,  no  matter  how  gently  this  may 
be  effected. 

During  the  progress  of  the  disease,  the  patient,  in  consequence 
of  the  constant  straining  to  which  he  is  subjected  whenever  he 
attempts  to  void  his  urine,  is  liable  to  suffer  from  hemorrhoids, 
prolapse  of  the  bowel,  and  even  hernia.  These  complications, 
which  are  suiRciently  conmion,  especially  in  elderly  persons, 
greatly  increase  the  local  distress,  and  assist  materially  in  under- 
mining the  general  health. 

The  urine  is  variously  altered  in  stricture,  according  to  the 
degree  of  irritation  of  the  urinary  bladder,  the  prostate  gland, 
the  ureters,  and  the  kidneys.  When  these  organs  participate  in 
the  mischief,  as  they  are  apt  to  do,  sooner  or  later,  they  throw 
oft^  an  unusual  amount  of  mucus,  which,  mingling  with  the 
urine,  imparts  to  it  a  remarkably  viscid,  ropy  character,  changes 
its  color,  and  induces  new  chemical  changes.  The  fluid,  which 
is  generally  loaded  with  saline  matter,  is  speedily  decomposed 


462  STRICTURE    OF    THE    URETHRA, 

on  exposure  to  the  atmospliere,  and,  in  fact,  often  even  in  the 
bladder,  emit;?  an  animoniacal  odor,  and  is  of  a  whitish,  lactes- 
cent, dark,  or  blackish  tint. 

Finally,  as  two  other  effects  of  stricture,  I  may  mention  here 
retention  and  incontinence  of  urine.  As  these  affections,  how- 
ever, have  been  already  fully  described,  I  Avill  merely  add  that 
the  first  is  the  most  common  in  the  milder  forms  of  the  malady, 
and  the  last  in  the  more  severe.  It  should  not,  however,  be 
forgotten  that  the  constant  dribbling,  witnessed  under  such  cir- 
cumstances, is  usuall}"  an  evidence  of  retention  rather  than  of 
incontinence ;  the  distinction  is  of  great  practical  consequence, 
and  a  correct  diagnosis  is  therefore  of  paramount  importance. 
AVhen  the  urine  passes  off  incessantly,  the  attendant  may  rest 
assured  that,  as  a  general  rule,  the  bladder  is  never  entirely 
empty,  but  that  a  certain  quantity  of  water  remains  in  its  more 
dependent  portion,  where  it  soon  becomes  a  source  of  irritation 
and  suffering. 

Although  the  symptoms  which  have  now  been  considered  are, 
in  general,  sufficiently  denotive  of  the  real  nature  of  the  disease 
which  produces  them,  they  can,  nevertheless,  not  be  regarded 
as  pathognomonic.  They  may  be  the  result  of  other  causes,  and 
are,  therefore,  rather  of  negative  than  positive  value.  To  estab- 
lish, in  an  unequivocal  manner,  the  diagnosis  in  any  given  case, 
it  is  indispensably  necessarj^  to  explore  the  urethra  with  some 
instrument.  The  one  which  I  us vially  select  for  this  purpose, 
is  a  common  silver  catheter,  large  enough  to  fill,  without  dis- 
tending, the  meatus,  and  rounded  at  the  extremity,  which  is 
passed  down  the  tube,  first  to  the  obstruction,  then  into  it,  and 
lastly,  if  possible,  beyond  it.  If  the  instrument  does  not  engage 
in  the  oiiening,  smaller  ones  are  to  be  successively  resorted  to, 
until  the  contraction  is  entered  and  slightly  grasps  the  catheter. 
In  this  way  the  calibre  and  locality  of  the  stricture,  and  its  nature, 
as  to  sensitiveness  or  irritability,  may  be  determined.  A  far 
better  and  more  accurate  means  of  exploration,  and  the  only  one 
which  conveys  any  reliable  idea  of  the  extent  and  multiplicity  of 
strictures,  is  the  soft  exploratory  bitlbous  bougie,  of  Leroy,  de- 
lineated in  fig.  129.  The  stem,  which  is  several  sizes  smaller  than 
the  acorn-shaped  bulb,  permits  it,  if  there  be  more  than  one  stric- 
ture, to  move  freely  in  the  first,  which  cannot  happen  with  the" 
ordinary  catheter.      On  its  witlidrawal,  the  abrupt    shoulder 


STRICTURE    OF    THE    URETHRA. 


46; 


Fi?.  139. 


comes  in  contact  with  the  posterior  face  of  the  coarctation,  and 
imparts  to  the  touch  a  sensation  as  if  it  had  jumped  over  an 
obstructing  band.  To  estimate  the  extent  of  a  stric- 
ture, a  number  which  corresponds  in  size  witli  that 
of  the  external  meatus,  is  carried  on  until  it  meets 
with  an  obstruction,  when  a  mark  is  made  upon  the 
stem  with  the  thumb-nail  on  a  level  with  the  meatus. 
Should  the  bulb  be  too  large  to  pass  through  the 
stricture,  smaller  ones  are  employed  until  the  object 
is  effected,  and  a  second  mark  made  when  it  meets 
with  resistance  during  its  withdrawal.  The  distance 
between  the  two  marks  indicates  the  length  of  the 
stricture. 

All  examinations  of  this  kind  should  be  conducted 
with  the  utmost  gentleness  and  deliberation,  lest 
spasm  and  pain  be  excited.  Bv  slow  and  cautious 
manipulations,  the  point  of  an  instrument  ma}'  often 
be  insinuated  into  the  tightest  stricture,  or  into  one 
so  tender  and  irritable  as  to  resent  every  attempt  of 
an  opposite  description. 

When  the  spongy  portion  of  the  urethra  is  affected, 
a  tolerably  correct  idea  of  the  nature,  seat,  and  extent 
of  a  stricture  may  sometimes  be  acquired  In^  the 
application  of  the  thumb  and  finger,  along  the  under 
surface  of  the  penis. 

Stricture  seldom  exists  long  without  giving  rise  to 
disease  in  the  adjoining  and  associated  parts.  The 
organs,  which,  besides  the  urethra,  are  more  liable  to 
suffer  are  the  prostate  gland,  the  bladder,  the  ureters,  and  the 
kidneys.  The  testes,  penis,  seminal  vesicles,  perineum,  and 
rectum,  also  not  imfrequently  participate  in  the  evils  consequent 
upon  the  malady.  The  affections  Avhich  thus  spring  up  during 
the  progress  of  the  mechanical  obstacle  of  the  uretlira,  are  often 
of  a  most  serious  character,  and  add  greatly  to  the  distress  and 
danger  of  the  ease. 

One  of  the  most  frequent,  as  well  as  the  most  serious,  lesions 
consequent  upon  stricture,  is  a  dilatation  of  the  urethra  behind 
the  seat  of  the  obstruction,  fig.  130,  from  one  of  my  preparations. 
This  is  evidently  owing  to  the  manner  in  wdiich  the  urine  is 
impelled  against  the  stricture  whenever  an  attempt  is  made  to 


u 

Exploiatoiy 
Bulbous 
Bougie. 


464 


STRICTURE    OF    THE    URETHRA. 


Dilatatioa  of  the  Urethra 
behind  the  Stricture. 


evacuate  it;  and  varies  in  degree  from  the  slightest  increase  of 
the  natural  calibre  of  the  canal  to  that  of  a  pouch  capable  of 
holding  an  almond,  a  pullet's  egg,  or  even 
a  mock  orange.  In  the  more  aggravated 
forms  of  the  atfection,  the  abnormal  reser- 
voir presents  the  appearance,  and  subserves 
the  purpose,  of  an  accessor}-  bladder,  which 
is  habitually  distended  with  urine.  The 
parietes  of  the  dilated  part  are  generally 
attenuated,  and,  therefore,  liable  to  give 
way  under  the  pressure  of  its  contents. 
The  enlargement  is  most  common  at  the 
membranous  and  prostatic  portions  of  the 
urethra,  but  may  take  place  at  any  point  of 
its  extent.  Sometimes  it  involves  nearly 
the  whole  length  of  the  canal,  and  is  so 
great  as  to  admit  a  middle-sized  linger. 

The  urethra  in  front  of  the  obstruction 
is  either  normal,  diminished,  or  dilated. 
The  latter  occurrence,  of  which  Sir  Charles  Bell  has  related  and 
iigured  a  most  extraordinary  example,  is  exceedingly  rare,  and 
cannot  be  satisfactorily  accounted  for  upon  any  known  patho- 
logical principles.  In  cases  of  long  standing,  and  especially  in 
those  which  are  accompanied  by  fistule  of  the  perineum,  allow- 
ing most  of  the  urine  to  escape  in  that  direction,  this  portion 
of  the  canal  is  sometimes  considerably  diminished,  but  seldom 
entirely  obliterated.  In  the  milder  forms  of  tlie  malady,  the 
passage  in  front  of  the  stricture  is  generally  natural. 

There  are  few  eases  of  organic  stricture  in  which  there  is  not 
more  or  less  inflammation  of  the  mucous  membrane  at,  and  for 
some  distance  bej^ond,  the  seat  of  the  obstruction.  The  greatest 
amount  usually  exists  behind  the  stricture,  but  there  is  not 
infrequently  a  good  deal  within  it,  as  well  as  in  front  of  it. 
The  disease  is  indicated  by  increased  vascularity,  and  sometimes, 
also,  by  a  deposition  of  Ij'mph. 

Another  consequence  of  stricture  is  the  development  of  fistule 
in  the  perineum,  caused  by  ulceration  or  rupture  of  the  inflamed 
mucous  membrane  behind  the  seat  of  the  obstruction,  and  the 
escape  of  a  small  quantity  of  urine  into  the  subjacent  tissues ;  or 
by  the   existence   of  irritation  exterior  to  the  canal,  and  its 


STRICTURE    OF    THE    URETHRA. 


465 


gradual  extension  to  its  interior.  In  either  case,  an  abscess,  or, 
what  is  worse,  a  slough,  is  formed,  followed  by  a  fistule,  through 
which  more  or  less  of  the  urine  continues  to  be  discharged  until 
the  stricture  upon  which  it  depends  is  removed. 

In  a  patient,  aged  twenty-two,  whom  I  attended  for  stricture 
of  the  urethra  in  the  autumn  of  1851,  a  remarkable  tumor 
existed  on  the  under  surface  of  the  penis,  giving  this  organ  a 
most  singular  and  grotesque  appearance,  sketched  in  fig.  131. 

Fig.  131. 


Urinary  Cyst  consequent  upon  Stricture  of  the  Urethra. 

Of  a  semiovoidal  shape,  it  was  of  solid  but  elastic  consistence, 
and  was  six  inches  and  a  half  in  circumference,  by  three  inches 
and  a  half  in  length.  It  had  been  first  noticed  about  three 
months  previously,  from  which  time  it  had  gradually  increased 
until  it  had  acquired  its  present  bulk.  It  was  entirely  free 
from  pain,  but  had  disqualified  the  young  man  for  sexual  inter- 
course, and  was  a  source  of  great  disquietude  to  him  on  account 
of  the  obscurity  of  its  character.  On  cutting  into  it,  it  was 
found  to  contain  an  ounce  of  clear,  limpid  tiuid,  and  to  be 
nothing  but  a  urinary  cyst,  the  inner  surface  of  which  was  per- 
fectly smooth  and  glossy.  At  the  inferior  part  of  the  tumor,  near 
its  centre,  was  a  small  fistulous  opening,  giving  vent  frequently 
to  a  little  urine,  and  always,  when  the  part  was  compressed,  to  a 
small  quantity  of  mucopurulent  fluid.  Tlie  urethra  contained 
two  very  tight  strictures,  of  two  years'  standing,  and  the  pro- 
30 


466 


STRICTUKE    OF    THE    URETHRA, 


Fig.  132. 


duct  of  a  violent  attack  of  gonorrhcBa ;  one  was  situated  just 
behind  the  external  orifice,  and  was  so  small  as  hardly  to  admit 
a  stout  bristle ;  the  other  was  three  inches  farther  back,  and 
also  very  firm  and  callous.  It  was  over  the  last  stricture  that 
the  cyst  here  described  was  situated ;  it  was  entirely  on  the 
outside  of  the  canal,  and  had  evidently  been  caused  by  a  rupture 
of  the  mucous  membrane,  followed  by  the  escape  of  urine,  and 
the  gradual  expansion  of  the  surrounding  connective  tissue. 
The  skin  was  entirely  free  from  discoloration,  but  was  a  good 
deal  thickened  by  interstitial  deposits. 

An  instance  of  a  somewhat  similar  character,  dependent,  how- 
ever, upon  external  injury,  and  a  want  of  parallelism  between 
the  ruptured  ends  of  the  urethra,  occurred  to  my  friend  Dr. 
Washington  L.  Atlee,  and  is  related  in  the  American  Journal 
of  the  Medical  Sciences  for  October,  1849. 

Another  effect,  and  that  by  no  means  an  infrequent  one,  espe- 
cially in  tight  and  old  stricture,  is  dilatation  of  the  openings  of 

the  mucous  follicles  of  the 
urethra,  particularly  at  the  site 
of  the  afiection,  and  of  the  ori- 
fices of  the  ducts  of  the  prostate, 
which  sometimes  become  so 
much  enlarged  as  readily  to  in- 
tercept the  beak  of  a  bougie  or 
catheter.  This  result  is  well 
shown  in  fig.  132,  from  Thomp- 
son, the  peculiar  retiform  ap- 
pearance being  due  to  the  inter- 
lacement of  the  septa  which 
intervene  between  the  enlarged 
orifices  of  the  ducts  of  the  pros- 
tate. 

It  was  formerly  supposed 
til  at  enlargement  of  the  prostate 
was  a  very  common  effect  of 
organic  stricture  of  the  urethra. 
Recent  and  more  accurate  ob- 
servation, however,  has  fully 
disproved  the  truth  of  this 
opinion,  and  shown  that  when  these  two  affections  coexist,  the 


Section  of  Urethra,  showing  very  narrow 
Stricture,  and  dilated  and  reticulated  Mem- 
brauous  and  Prostatic  Poitions  behind  it. 


STRICTURE    OF    THE    URETHRA.  467 

circurastance  is  generally  to  be  regarded  as  purely  accidental. 
Altlioiigli  enlargement  is  infrequent,  this  gland  unfortunately 
often  sutlers  in  other  respects.  The  most  common  lesion,  in 
tight,  callous,  and  protracted  stricture,  is  inflammation  of  the 
substance  of  the  organ,  eventuating  occasionally  in  suppuration, 
the  development  of  an  abscess,  the  formation  of  calculous  con- 
cretions, complete  atrophy,  or  the  degeneration  of  the  gland  into 
a  membianous  pouch.  From  extension  of  the  irritation,  an 
abscess  sometimes  forms  between  the  bladder  and  the  rectum, 
causing  excessive  suffering,  and  ultimately,  perhaps,  a  fistulous 
communication. 

The  bladder,  in  confirmed  cases,  soon  becomes  hypertrophied, 
and  finally  sacculated,  while  its  capacity  is  either  diminished 
or  increased,  generally  the  former.  So  common,  indeed,  is  this 
coincidence,  that  it  must  always  be  viewed  in  the  light  of  cause 
and  effect.  The  lining  membrane  is  in  a  constant  state  of  in- 
flammation, attended  with  an  inordinate  deposit  of  mucous,  and 
even  mucopurulent,  fluid.  Another  occurrence,  worthy  of  pass- 
ing notice,  is  the  proneness,  in  patients  affected  with  this  malady, 
to  the  development  of  urinary  calculi.  This  subject,  like  that 
of  hjqiertrophy  of  the  bladder,  has  been  already  fully  discussed 
in  its  appropriate  place. 

The  ureters  frequently  participate  in  the  disorders  which  arise 
in  the  progress  of  organic  stricture.  The  most  common  lesion 
is  inflammation  of  their  lining  membrane,  with  suppuration  and 
deposits  of  h^mph,  and  irregular  dilatation  of  their  calibre.  Their 
parietes  are  sometimes  considerably  thickened,  or  thickened  at 
some  points  and  attenuated  at  others;  and  occasionally  they 
exhibit  a  strictured,  nodose,  or  puckered  appearance.  Cases 
occur  in  which  one  of  these  tubes  is  sometimes  very  much  con- 
tracted, or  nearly  obliterated. 

The  kidneys  are  variously  affected  in  this  disease.  Inflam- 
mation frequently  occurs  at  an  early  period,  and  gradually 
progresses  until  it  ends  in  serious  mischief,  if  not  in  total  ruin  of 
the  affected  organ.  The  malady  seldom  exists  i)i  the  same 
degree  in  both  viscera.  Sometimes  one  is  entirely  healthy,  or 
nearly  so,  while  the  other  is  converted  into  a  large  abscess,  filled 
with  serous  cysts,  inflamed,  hypertrophied,  granulated,  or 
changed  into  a  membranous  pouch,  devoid  of  renal  tissue. 


468 


STRICTURE    OF    THE    URETHRA. 


Ficr   1"3. 


The  adjoiiiiiig  sketcli,  fig.  13o,  strikingly  illustrates  the  effects 
of  stricture  of  the  urethra  u[)on  the  rest  of  the  urinary  organs. 
The  prostate  gland  is  conijiletely  destroyed,  the  mucous  mem- 
brane of  the  bladder  is  removed  by 
ulceration,  the  ureter  is  immensely 
enlarged,  and  the  kidney  is  converted 
into  a  mere  shell,  which  was  filled  at 
tlie  time  of  the  dissection  with  puru- 
lent matter.  The  drawing  is  from  a 
specimen  in  the  pathological  collec- 
tion of  the  ]^ew  York  Hospital. 

The  testes  are  prone  to  suffer  in 
stricture,  apparently  from  continuous 
sympatln',  or,  more  properly  speak- 
ing, from  direct  irritation.  In  many 
cases  they  become  morbidlj'  sensitive ; 
and  it  is  not  uncommon  for  one  or 
both  to  be  swollen  and  indurated. 
The  irritation  occasionally  extends 
to  the  vaginal  tunic,  antl  produces 
hydrocele.  The  spermatic  cords  are 
sometimes  remarkably  tender,  or  en- 
larged and  unnaturally  hard. 

The  seminal  vesicles  are  also  liable 
to  suffer;  their  lining  membrane  be- 
comes inflamed,  and,  in  cases  of  long 
standing,  their  volume  is  occasionally 
remarkably  diminished,  at  the  same 
time  that  their  coats  are  very  firm, 
dense,  and  contracted. 

One  of  the  most  singular  occur- 
rences in  old  and  severe  strictures 
of  the  urethra  is  an  inordinate  develoi'ment  of  the  penis.  The 
whole  organ  is  not  only  elongated  but  remarkably  thick,  hard, 
and  rigid;  a  circumstance  which  appears  to  be  owing,  not  so 
much  to  the  irritation  of  the  neck  of  the  bladder,  which  often 
exists  in  a  high  degree  in  this  disease,  as  to  the  milking  efforts, 
if  T  may  so  express  mj-self,  which  the  patient  is  constantly 
obliged  to  make  in  order  to  promote  the  flow  of  urine  through 


Effects  of  Stricture  on  the  Urinary 
Organs. 


STRICTURE    OF    THE    URETHRA.  469 

the  obstructed  urethra.     For  the  same  reason,  the  prepuce  is 
often  remarkably  swollen  and  cedematous. 

Finally,  a  stricture  of  the  -urethra  occasionally  makes  a  verv 
injurious  impression  upon  the  nervous  system,  due,  apparently, 
to  reflex  irritation.  Thus,  in  a  case  recorded  by  Sir  Benjamin 
Brodie,  the  disease  induced  lameness  and  pain  in  the  foot,  which 
were  promptly"  relieved  by  the  use  of  the  bougie. 

The  prognosis  of  stricture  is  variable.  If  taken  in  hand  before 
it  has  become  hard  and  firm,  or  while  it  is  still  recent,  and  before 
it  has  given  rise  to  any  serious  lesion  of  the  urinarj'  apparatus, 
it  is,  in  general,  neither  dangerous,  nor  ditflcult  of  cure.  It  is,  in 
fact,  under  such  circumstances,  rather  an  inconvenience  than  a 
disease.  When,  however,  it  has  made  considerable  progress, 
offers  much  resistance  to  the  passage  of  the  urine,  and  has  excited 
inflammation  in  the  neighboring  organs,  it  may  be  considered 
as  a  very  serious  aflfection,  liable,  if  permitted  to  proceed,  to  be 
followed  by  the  worst  consequences,  as  may  be  gathered  from 
the  account  which  has  just  been  given  of  its  pathological  effects. 
As  a  general  rule,  it  may  be  stated  that  a  recent  stricture  is 
much  more  easy  of  cure  than  an  old  one ;  a  small  than  a  large 
one;  a  soft  than  a  callous  one;  an  inflammatory  than  atrau- 
matic one.  Furthermore,  a  stricture  of  the  membranous  portion 
of  the  urethra  is  usually  harder  to  manage  than  one  of  the 
spongy,  chiefly  because  tbe  former,  in  consequence  of  its  depth 
and  the  parts  by  which  it  is  embraced,  is  less  under  our  control 
than  the  latter,  which  is  comparatively  accessible.  An  obstruc- 
tion in  this  situation  is  also  more  liable,  as  a  general  principle, 
to  awaken  serious  disease  of  the  prostate  gland,  the  urinary 
bladder,  the  ureters,  and  the  kidneys. 

When  a  stricture  is  old  and  callous  it  is  not  only  irradicable, 
but  it  may  gradually  so  far  undermine  the  general  health  as  to 
cause  death;  or  life  may  be  assailed  by  the  supervention  of 
retention  of  urine,  or  by  the  extravasation  of  this  fluid  into  the 
perineum  or  scrotum,  in  consequence  of  a  laceration  of  the  ure- 
thra, or  by  rupture  of  the  bladder.  The  immediate  cause  of 
death  is  sometimes  a  small  calculus  plugging  up  the  canal  behind 
the  stricture,  thereby  preventing  the  discharge  of  the  urine. 
When  the  health  is  much  impaired  from  protracted  vesical  or 
renal  complications,  the   brain  sometimes   sympathizes  in  the 


470 


STRICTURE    OF    THE    URETHRA. 


Fio;.  134. 


general  disorder;  a  slow  subacute  inflammation,  attended  by 
coma,  is  set  up  in  this  organ  and  in  the  araclmoid  membrane; 
and  the  patient  at  length  dies  from  serous  effusion. 

Various  methods  are  employed  for  effecting  the  permanent 
cure  of  stricture.  Of  these  the  most  important,  and  consequently 
the  most  worthy  of  notice,  are  dilatation,  rupture,  incision,  and 
external  division,  each  of  which  has  been  more  or  less  modified, 
according  to  the  wants,  whims,  or  caprices  of  different  prac- 
titioners. It  must  be  obvious,  at  a  glance,  that  these  methods, 
so  opposite  in  their  character  and  design,  are  not  equally  adapted 
to  all  forms  of  the  disease  which  they  are  in- 
tended to  remedy.  Hence,  also,  it  will  be  per- 
ceived that  there  is  a  necessity,  not  only  for 
describing  these  procedures,  considered  as  so  many 
distinct  operations,  but  also  for  pointing  out  the 
cases  to  which  each  in  jDarticular  is  applicable. 

Before  resorting  to  any  of  these  expedients,  it 
is  of  paramount  importance,  I  conceive,  to  attend 
to  the  general  health,  and  to  subdue  local  inflam- 
mation, tenderness,  and  spasm.  Unless  this  be 
done,  the  practitioner  will  be  mvich  more  likely 
to  do  harm  than  good.  To  effect  this  object,  the 
patient  should  be  kept  in  the  recumbent  posture 
for  six  or  eight  days  previous  to  the  intended 
operation;  the  bowels  should  be  freely  moved 
every  forty-eight '  hours  with  some  mild  purga- 
tive; the  secretions  should  be  duly  regulated;  the 
diet  should  be  light  and  unirritant;  and  recourse 
should  be  had  occasionally  to  the  warm  bath.  If 
there  be  any  inflammation,  irritation,  or  spasm  of 
the  urethra  and  the  bladder,  leeches  must  be  ap- 
plied to  the  perineum,  followed  by  fomentations 
and  anodyne  enemata.  Demulcent  drinks  should 
also  be  used ;  and  there  are  few  cases  which  will 
not  be  benefited  by  the  exhibition  of  bicarbonate 
of  soda  and  balsam  of  copaiba. 
When  the  urethra  is  irritable,  particularly  if  the  case  is  to 
be  subjected  to  ru[tture  or  incision,  the  excessive  sensitiveness 
must  be  subdued  by  the  methodical  introduction  of  a  conical 


Porte-Caustique. 


STRICTURE    OF    THE    URETHRA.  471 

steel  bougie  and  stimulating  injections.  Great  benefit  may  be 
derived,  especially  if  the  part  be  studded  with  granulations,  from 
cauterization  with  nitrate  of  silver.  The  operation  is  performed 
with  the  porte-caustique,  represented  in  fig.  134,  aii  instrument 
which  I  devised  many  years  ago,  and  which  is  far  superior, 
in  point  of  safety,  to  that  of  Lallemand,  still  so  much  used 
in  this  country.  It  is  shaped  like  a  catheter,  and  is  closed  at 
its  vesical  extremity,  near  which,  on  its  convexity,  there  is 
an  elongated  aperture,  through  which,  by  means  of  a  cup  at- 
tached to  the  stylet,  filled  with  extract  of  hyoscyamus  and  pow- 
dered nitrate  of  silver,  the  caustic  is  brought  fairly  in  contact 
with  the  affected  surface  by  a  rotary  movement  of  the  instru- 
ment. The  operation  usually  causes  some  pain  and  scalding, 
and  is  followed  by  an  increase  of  the  discharge;  but  these  symp- 
toms disappear  in  four  or  five  days. 

Too  much  stress  cannot  be  placed  upon  this  preliminary  treat- 
ment; indeed,  I  should  consider  it  highly  culpable  to  neglect  it 
under  any  circumstances.  When  the  way  has  been  thus  paved, 
the  particular  kind  of  treatment  is  to  be  determined  by  a  careful 
consideration  of  the  nature  of  the  obstruction.  There  are  few 
points  in  surgery  which  require  more  judgment  and  experience 
than  this. 

Some  practitioners  are  in  the  habit,  in  their  attempts  to  cure 
organic  stricture,  of  relying  mainly  upon  constitutional  means, 
especially  rigid  abstinence,  carried  almost  to  starvation,  and  the 
daily  use  of  nauseating  doses  of  tartarized  antimony,  or  the 
frequent  exhibition  of  emetics ;  conjoined  with  rest  in  the  re- 
cumbent posture,  and  the  avoidance  of  all  sources  of  bodily 
excitement.  That  such  a  mode  of  treatment  is  well  calculated 
to  allay  vascular  action,  and  promote  the  absorption  of  the 
eftused  lymph  which  gives  rise  to  the  obstruction,  may  be  readily 
imagined ;  but  any  advantages  thus  accruing  are  generally  more 
than  counterbalanced  by  the  hardships  which  attend  it.  In  the 
callous  form  of  the  disease,  such  a  proceeding  must  be  perfectly 
futile;  for  there  are  few  cases  which  can  receive  any  permanent 
benefit  from  it,  and  in  which  it  will  not  be  more  likely  to  wear 
out  the  patient  than  his  stricture.  Of  a  consideral)lc  number  of 
persons  whom  I  have  known  to  be  treated  upon  this  principle, 
I  do  not  recollect  a  single  one  who  experienced  any  decisive  or 


472 


STRICTURE    OF    THE    URETHRA. 


Fisr.  135. 


permanent  relief,  or  who  was  willing  again  to  submit  to  its 

exorbitant,  unscientific,  and  injurious  exactions. 

The  object,  in  any  mode  of  treatment,  being  the  restoration 

of  the  normal  calibre  of  the  urethra,  it  naturally  follows  that 
no  measure  Avill  be  successful  unless  the  size  of  the 
canal  be  previously  ascertained  in  each  individual 
case,  and  the  contracted  part  be  brought  up  to  that 
standard.  Hence,  a  careful  exploration  should  alwa3's 
be  made  with  the  urethrometer,  devised  by  Dr.  Otis, 
and  represented  in  fig.  ISo.  Being  well  oiled  and 
passed  in  its  closed  state,  by  means  of  the  screw  at 
the  handle,  the  bulb  is  expanded  to  the  point  ot 
filling  the  urethra  comfortably,  without,  however, 
interfering  with  its  being  moved  easily  and  pain- 
lessly backwards  and  forwards,  when  the  index  on 
the  dial  shows  the  normal  circumference  of  the  canal 
in  millimetres,  which  is  the  standard  of  measurement 
in  the  French  catheter  scale.  It  should  be  remem- 
bered that  a  millimetre  is  equal  to  5'-  of  an  inch. 
In  the  absence  of  this  instrument,  the  size  of  the 
urethra  may  be  determined  quite  accurately  by 
taking  tlie  circumference  of  the  flaccid  penis,  be- 
tween which  and  the  calibre  of  the  canal,  a  constant 
relation  exists,  as  was  first  pointed  out  by  Dr.  Otis. 
Thus,  a  circumference  of  3  inches  indicates  a  calibre 
of  30  millimetres,  or  one  inch  and  one-fifth,  while 
each  additional  quarter  of  an  inch  in  circumference 
represents  an  increase  of  two  millimetres  in  the 
calibre  of  the  urethra.^ 

In  estimating  its  normal  size,  it  must  not  be  for- 
gotten that  the  urethra  varies  at  difl:erent  portions 
of  its  extent.  Thus,  it  always  presents  two  contrac- 
tions, one  at  the  external  meatus  and  one  at  the  bulbo- 
membranous  junction,  and  two  dilatations,  which  are 
seated  respectively  in  the  navicular  fossa  and  in  the 
sinus  of  the  bulb.     The  meatus  beins:  the  narrowest 


Dr.  Otis's  Ure- 
tlirometer. 


1  From  a  number  of  measurements  made  upon  private  and  hospital  cases,  the 
editor  is  enabled  to  add  additional  confirmatory  evidence  of  the  correctness  of 
the  estimates  of  Dr.  Otis. 


STRICTUEE    OF    THE    URETHRA.  473 

portion,  it  is  not  the  true  index  of  the  calibre  of  the  canal  T)eyon(I 
that  point,  and  should  not  be  used  as  a  gauge  for  the  passage  of 
instruments,  although  a  catheter  which  enters  the  orifice  should 
pass  readily  into  the  bladder  unless  there  be  an  obstruction. 
The  widest  and  most  dilatable  portions  of  the  urethra  are  at  the 
bulb  and  the  navicular  fossa,  the  former  being  the  larger  by  two 
millimetres  and  a  half,  or  one-tenth  of  an  inch,  while  the  calibre 
of  the  spongy  portion  is  intermediate  between  the  two.  Hence, 
if  a  stricture  be  seated  in  the  bulb,  and  the  urethrometer  shows 
the  spongy  urethra  in  front  of  it  to  be  equal,  for  example,  to  25 
of  the  French  scale,  the  only  rational  practice  will  be  to  bring 
the  calibre  of  the  contracted  part  up  to  30  millimetres,  since,  in 
its  normal  state,  the  circumference  of  the  bulbous  portion  is 
greater  by  two  millimetres  and  a  half  than  that  of  the  spongy 
portion,  and  the  canal  should  be  dilated,  as  can  easily  be  done, 
to  twice  that  extent,  which  represents  its  real  size  when  it  is 
ordinarily  stretched.  Again,  if  the  navicular  fossa  measures  27 
millimetres,  and  the  stricture  be  situated  in  the  spongy  portion 
anterior  to  the  bulb,  the  latter  should  be  made  to  correspond  to 
about  25  of  the  French  scale,  as  the  spong}^  portion  is  naturally 
not  so  capacious  as  the  former  locality.  In  other  words,  instead 
of  taking  any  one  point  of  the  urethra  as  the  standard  for  the 
whole,  the  normal  relations  of  its  individual  portions  must  be 
preserved. 

In  all  instances,  the  meatus  should  be  enlarged  if  it  interferes 
with  the  passage  of  an  instrument  of  the  size  adapted  to  restor- 
ing the  constricted  part  to  its  original  dimensions,  as  indicated 
b}^  the  urethi-ometer. 

1.  Dilatation. — This  process  was  applied  to  the  cure  of  stricture 
at  an  early  period  of  the  profession,  and  was  for  a  long  time  the 
only  one  in  use.  Notwithstanding  the  various  attempts  that 
have  been  made  to  supersede  it,  and  the  reproaches  that  have 
been  cast  upon  it  by  modern  writers,  it  still  maintains  its  j.laee 
in  the  estimation  of  enlightened  practitioners,  and  there  can  be 
no  doubt  that  it  is  frequently  applicable  to  simple,  soft,  and 
recent  strictures,  while  it  is  often  demanded  to  prepare  tlie  way 
for  other  measures. 

Dilatation  maybe  performed  either  gradually  or  continuously, 
and  for  this  purpose  various  instruments  have  been  recommended, 


474 


STRICTURE    OF    THE    URETHRA. 


those  usually  employed  being  the  soft  French  elastic  bougies,  the 
silver  catheter,  and  the  nickel-plated  steel  bougie.  Their  sizes 
are  graduated  by  a  scale,  of  which  by  far  the  best,  and,  indeed, 
the  only  accurate  one,  is  the  Trench,  represented  in  fig.  136. 
The  numbers  range  from  1  to  30,  and  their  increase  in  size  is 
uniform,  being  one  millimetre  in  circumference,  N"o.  3  being 
equal  to  No.  1,  and  No.  30  equal  to  No  18,  of  the  English  gauge. 


Fig.  13G. 


f  r^ 

-^ 

O 

ro  o 
w  o 

/-'^ 

^  o 

o 

CJ1   o 

05  o 

o 

o 

SO 

o 

^O 

o 
o 

^O  ^ 

sO 

^O 

"O 

M^^, 

^K^ 

sO 

o 

^o 

o 

[^o 

Oy 

Fig.  Fig.  Fig.  Fig. 
137.  138.  139. 140. 


Gum-elastic  Bougies. 

The  soft  bougies  are  especially  service- 
able in  untrained  hands  for  strictures 
below  No.  15,  of  the  French,  or  No.  9  of 
the  English  scale,  and  they  are  some- 
times indispensable  to  overcome  tortuous  strictures.  Those  with 
conical  extremities,  figs.  138, 139,  are  useful  in  tight  and  narrow 


French  Catheter  Scale. 


STEICTTJEE    OF    THE    URETHRA.  475 

cases  ;  but  when  the  disease  is  of  long  standing  and  attended 
with  enlargement  of  the  openings  of  the  mucous  follicles  and 
prostatic  ducts,  the  addition  of  an  olivary  tip,  as  in  fig.  137, 
prevents  their  becoming  entangled  in  these  pouches.  The  bellied 
bougie,  fig.  140,  is  used  to  dilate  the  stricture  alone,  as  the  stem, 
from  its  greater  narrowness,  does  not  act  upon  the  remainder  of 
the  canal  and  subject  it  to  unpleasant  distention. 

My  conviction,  founded  upon  ample  experience,  is  that  the 
best  and  least  irritating  instrument  for  dilating  a  stricture  is  the 
nickel-plated  steel  bougie,  fig.  144,  with  a  short  curve,  provided 
with  a  heavy  handle,  and  terminating  in  a  somewhat  conical 
point.  Its  great  advantages  are  its  smoothness  and  its  weight, 
which  facilitate  its  onward  passage  without  the  risk  of  making 
a  false  route.  If  the  surgeon  will  only  have  confidence  in  this 
instrument,  and  allow  it  to  remain  in  contact  with  the  face  of  a 
stricture  until  the  spasm  provoked  by  its  presence  is  overcome, 
he  will  rarely  have  to  resort  to  soft  instruments  or  temporize 
with  those  of  small  size. 

a.  In  gradual  or  temporary  dilatation  the  object  is  to  proceed 
as  cautiously  as  possible,  so  as  to  avoid  all  risk  of  irritation, 
commencing  with  an  instrument  that  will  readily  pass  the  ob- 
struction, and  using  afterwards  a  series  of  steadily  increasing 
sizes  until  the  treatment  is  perfected.  The  introduction  is  re- 
peated every  second  or  third  da}-,  commencing  at  each  sitting 
with  the  one  last  used,  and  following  it  with  a  size  larger,  until 
the  normal  calibre  of  the  urethra  is  attained.  At  first,  the  bougie 
should  be  conveyed  into  tbe  bladder,  and  be  immediately  with- 
drawn ;  but  as  the  canal  becomes  more  tolerant  of  its  presence, 
it  should  be  retained  for  five  minutes. 

In  the  management  of  very  tight,  or  tortuous  strictures,  and 
strictures  complicated  by  great  induration  of  the  perineum,  it  is 
sometimes  impossible  to  overcome  the  obstacle  with  tlie  ordinary 
instruments,  wdien  the  olivary  whalebone  filiform  bougies,  fig. 
141,  will  prove  invaluable.  Those  with  spiral  points,  or  bent  at 
an  angle  near  their  extremities,  are  especially  serviceable  when 
the  opening  of  the  obstruction  is  eccentric.  Their  passage  is 
facilitated  by  previously  injecting  the  urethra  with  oil,  and  im- 
parting to  them  a  rotary  movement,  es[)ecially  if  the  i>aticnt 
be  anfesthetized. 


476 


STRICTURE    OF    THE    URETHRA. 


Fig.  141. 

/' 


A  false  passage,  the  usual  seat  of  ■which  is  the  floor 
of  the  urethra,  complicating  a  stricture,  is  hest 
avoided  by  the  angular  instrument  of  Mercier, 
represented  in  fig.  16,  which  is  the  only  contri- 
vance by  which  the  roof  of  the  canal  can  be  closely 
hugged.  When  the  opening  is  situated  in  the  upper 
surface  of  the  urethra,  it  may  be  avoided  by  the 
olivarj'  bougie,  represented  in  fig.  137.  In  the 
event  of  the  failure  of  these  instruments,  another 
resource,  and  one  that  is  often  attended  with  success, 
is  packing  the  urethra  with  filiform  whalebone 
bougies,  which  engage  in  the  false  passage,  until  one 
slips  on  through  the  stricture  into  the  bladder. 

Finally,  the  plan  of  ^Nlercier  may  be  resorted  to. 
This  consists   in   introducing   a    metallic   catheter, 
which  is  solid  up  to  the  dotted  line,  as  represented  in. 
fig.  142,  into  the  false  passage,  and  then  protruding, 

FU.  142. 


Mercier's  Catheter  for  avoiding  a  False  Passage. 

at  the  eye  on  its  concavity,  an  elastic  instrument, 
which  may  be  guided  into  the  true  route,  when 
the  metallic  catheter  is  withdrawn. 

The  treatment  by  gradual  dilatation  is,  in  the  end, 
very  unsatisfactory,  relapses  being  the  rule,  and  com- 
plete cures  the  exception.  Its  success  is  based  upon 
the  action  of  the  absorbent  vessels,  stimulated  by 

/the  contact  of  the  instrument  to  the  removal  of 
the  new  tissue,  upon  the  presence  of  which  the  ob- 
^  struction  depends.  It  is,  therefore,  onl}^  appli- 
cable to  very  recent  cases,  for  when  the  disease  is 
confirmed,  it  never  induces  entire  absorption  and 
disappearance  of  the  cicatricial  new  formation.  Hence,  dilata- 
tion, if  positively  and  methodically  persisted  in,  is  useful  as  a 
palliative  measure,  as  it  Avill  prevent  tlie  occurrence  of  serious 


Filiform 
Bougies. 


STRICTUEE    OF    THE    URETHRA.  477 

secondary  lesions,  and  render  the  patient  comparatively  com- 
fortable during  the  remainder  of  his  life.  It  is  inapplicable  to 
strictures  at  or  near  the  meatus,  and  to  impassable,  very  sensi- 
tive, resilient,  traumatic,  and  complicated  coarctations. 

^.  When  a  stricture  is  so  tight  as  to  give  rise  to  considerable 
difficulty  in  its  penetration,  especially  when  it  is  of  an  obstinate, 
sensitive,  or  of  a  contractile  nature  ;  when  the  case  is  complicated 
by  false  passages,  or  when  the  patient  is  unable  or  unwilling  to 
subject  himself  to  the  slower  method  of  gradual  dilatation,  per- 
manent or  continuous  dilatation  becomes  a  valuable  substitute. 
For  this  purpose,  the  pliant  catheter,  represented  in  lig.  18,  p. 
114,  is  retained  in  the  bladder  until  it  becomes  loosened,  which 
usually  happens  within  the  first  fortj'-eight  hours,  the  patient 
in  the  meanwhile  being  confined  to  his  bed.  It  is  important, 
with  the  view  of  guarding  against  pain  and  constitutional  dis- 
turbance, that  the  instrument  should  merely  fill,  without  over- 
stretching, the  obstruction,  and  that  its  beak  should  lie  in  the 
neck  of  the  bladder,  without  entering  that  viscus.  The  original 
instrument,  when  loosened,  is  replaced  by  one  several  sizes  larger, 
and  the  treatment  is  thus  continued  until  the  normal  calibre  of 
the  urethra  is  attained. 

In  whatever  manner  the  dilatation  be  conducted,  whether 
gradually  or  continuously,  it  is  of  paramount  importance,  after 
the  cure  is  apparently  completed,  to  introduce  occasionally  a 
full-sized  bougie  as  far  as  the  bladder.  This  may  be  done,  at 
first,  every  third  or  fourth  day,  then  once  a  week,  then  every 
fortnight,  and  at  length  once  a  month.  Where  this  precaution 
is  neglected,  little  hope  can  be  entertained  of  permanent  pallia- 
tion ;  and  the  practitioner  has  sometimes  the  mortification  to 
find  a  relapse  in  a  few  weeks.  Before  the  patient  is  finally  dis- 
missed, he  should  be  taught  the  introduction  of  the  instrument. 

2.  Rupture.— In  rupture,  splitting,  laceration,  divulsion,  forci- 
ble dilatation,  or  the  immediate  treatment,  as  this  method,  which 
is  generally  known  as  that  of  Mr.  Barnard  Holt,  of  London,  but 
was  long  ago  practised  by  myself  and  others,  is  variously  termed, 
the  object  is  to  lacerate  the  contracted  part  up  to  the  full  calibre 
of  the  normal  passage,  through  which  a  splice,  if  the  expression 
may  be  used,  softer,  more  extensible,  and  less  contractile  tlian 
the  tissues  of  the  stricture,  is  inserted  into  the  urethra.  The 
instrument  with  which  it  is  performed  is  some  one  of  the  improve- 


478 


STRICTURE    OF    THE    URETHRA. 


Fie. 


Fiff.  144. 


mcnts  upon  the  original  dilator  of  Perreve,  of  which  one  of  the 
most  perfect  is  that  of  Dr.  Richardson,  of  Duhlin,  represented  in 
fig.  143.  Having  l>een  passed  closed,  with  the  aid  of  the  index- 
finger  in  the  rectum,  if  necessary,  into  the  bladder,  a  dovetailed 
plunger,  which,  with  the  expanded  blades,  equals  the  calibre  of  the 
urethra,  as  ascertained  by  previous  measurement,  is  rapidly  forced 
onwards  between  the  blades,  when  the  instrument 
is  rotated  several  times  so  as  to  enlarge  the  rent, 
and  withdrawn.  The  bladder  having  been  evacu- 
ated with  a  catheter,  ten  grains  of  quinine  and 
one-third  of  a  grain  of  morphia  are 
administered,  with  the  two-fold  ob- 
ject of  preventing  an  attack  of  ure- 
thral fever,  or  mitigating  its  violence, 
if  it  should  arise,  and  relieving  pain, 
and  the  patient  kept  in  bed  for  fort}'- 
eight  hours. 

When  the  stricture  is  so  tight  as 
to  admit  of  the  passage  merely  of  a 
filiform  bougie,  the  vesical  extremity 
of  the  instrument  may  be  perforated 
and  grooved,  through  which  it  may 
be  slipped  over  the  bougie,  acting  as 
a  o-uide,  down  to  and  through  the 
obstruction.  For  this  useful  im- 
provement on  urethral  instruments, 
the  profession  is  indebted  mainly  to 
Dr.  Gouley,  of  ISTew  York. 

Instead  of  employing  the  ordinary 
form  of  dilator,  I  have  for  several 
years  divulsed  strictures  with  the 
heavy,  conical,  nickel-plated  steel 
bougie,  tig.  144,  which  from  its  point 
to  its  shaft  represents  six  sizes  of  the 
French  scale,  the  smallest  running 


Richardsou's 


Tanueiied-Handied  from   1 1   at  thc  cxtrcmity  to  16  at 
the  shaft,  and  the  largest  from  25  to 
30,  beyond  which  size  I  have  rarely  had  occasion  to  go.     Six  of 
these  instruments  usually  answer  every  purpose,  and,  while  they 
act  equally  as  etlectual  as  the  divulsor,  by  being  rapidly  inserted 


STRICTURE    OF    THE    URETHRA.  479 

one  after  another,  they  are,  according  to  my  experience,  far 
superior  to  it,  especially  when  the  stricture  is  seated  at  the  sub- 
pubic curvature,  where,  unless  very  great  care  is  exercised,  there 
is  always  danger  in  unskilled  hands  of  the  divulsor  making  a 
false  passage. 

The  operation  of  rupture  with  either  of  these  instruments 
may  be  said  to  be  absolutely  free  from  danger,  unless  there  is 
advanced  renal  disease.  It  is  never  followed  by  serious  hemor- 
rhage, and  wdiat  bleeding  there  is  usually  promptly  ceases  spon- 
taneously. I  have  never  known  it  to  give  rise  to  imj  untoward 
symptoms ;  it  fulfils  the  same  indications  as  internal  urethrotomy  ; 
is  applicable  to  all  forms  of  stricture,  and  is  especially  avail- 
able for  resilient,  irritable,  and  traumatic  coarctations  of  the 
curved  urethra,  and  it  is  more  expeditious  than,  at  the  same 
time  that  it  is  as  safe  as,  the  apparently  simpler  procedures. 
For  these  reasons  I  do  not  hesitate  to  give  it  my  unqualified 
approval.  Internal  incision  is,  how^ever,  preferable  when  the 
disease  is  seated  at  or  near  the  meatus,  and  in  the  spongy  por- 
tion anterior  to  the  curve,  and  when  the  new  deposit  is  thick 
and  dense. 

In  conducting  the  operation  there  are  two  important  points 
which  cannot  be  too  forcibly  impressed  upon  the  surgeon's  atten- 
tion, namely,  that  unless  the  laceration  involves  the  mucous 
membrane,  as  denoted  by  the  occurrence  of  hemorrhage,  its 
object,  which  is  to  insert  a  splice  into  the  contracted  part,  wnll 
be  defeated ;  and,  secondly,  that  a  full-sized  exploratory  bougie 
should  be  passed  with  the  view  of  detecting  any  bands  tliat  may 
have  escaped  the  action  of  the  divulsor.  In  the  latter  event,  the 
operation  should  be  completed  wdth  the  urethrotome  represented 
in  fig.  146.  Unless  these  points  are  carefully  attended  to,  the 
X>rocedure  wnll  not  be  followed  by  a  permanent  result,  and  will 
be  brought  into  disrepute. 

The  after-treatment  of  rupture  is  conducted  on  general  prin- 
ciples. At  the  expiration  of  forty-eight  hours,  a  full-sized  bougie 
is  inserted,  and  the  convexity  of  its  curve  pressed  against  the 
seat  of  the  laceration,  with  a  view  of  stretching  the  newly  formed 
cicatricial  tissue,  and  thereby  preventing  its  contraction.  The 
introduction  of  the  instrument  is  subsequently  repeated  every 
second  day  until  the  healing  process  is  perfected,  which  is  denoted 
by  freedom  from  hemorrhage  and  pain.     If  the  stricture  have 


480  STRICTURE    OF    THE    URETHRA. 

been  thoroughly  divided,  I  have  every  reason  to  believe,  more 
especially  in  simple  cases,  that  nothing  more  need  be  done ;  but 
if  the  coarctation  is  extensive  and  dense,  as  a  matter  of  precau- 
tion, the  bougie  should  be  i)assed  in  accordance  with  the  prin- 
ciples laid  down  in  the  preceding  section. 

3.  Internal  Urethrotomy. —  All  permeable  strictures,  whether 
simple,  irritable,  resilient,  gonorrhoeal,  or  traumatic,  provided 
the}'  are  not  complicated  by  great  thickening  and  induration 
of  the  periurethral  tissues,  are  best  treated  by  internal  incision  ; 
while  for  coarctations  situated  at  the  meatus  and  in  the  first 
four  inches  and  a  half  of  the  spongy  portion  of  the  urethra,  it 
is  the  only  measure  which  holds  out  the  slightest  prospect  for 
a  radical  cure.  Rupture  is  equally  applicable  to  the  affection, 
when  located  at  the  subpubic  curvature  and  its  vicinity ;  but 
internal  urethrotomy  possesses  the  advantage  of  completely 
severing  all  resisting  bands,  some  of  which  are  liable  to  escape 
the  action  of  the  divulsor;  thereby  necessitating  a  resort  to  a 
cutting  instrument  to  finish  the  operation,  and  thus  afl:brd 
immunity  from  relapse.  I  have  performed  the  operation  too 
frequently  not  to  be  convinced  of  its  superiority,  as  to  enduring 
results,  over  all  other  plans ;  and  I  have  repeatedly  had  under 
my  charge  [latients  with  simple  stricture  who  had  been  subjected 
to  ordinary  dilatation  for  months  and  months,  without  any 
permanent  benefit,  and  who  were  almost  instantly  relieved  by 
it.  In  the  absence  of  disease  of  other  portions  of  the  urinary 
tract,  it  is  a  perfectly  safe  procedure ;  while,  if  there  be  serious 
renal  trouble,  it  is  just  as  dangerous  as,  but  not  more  than,  other 
modes  of  treatment. 

For  strictures  at  or  near  the  external  orifice,  the  only  instrument 
required  is  a  narrow-bladed,  probe-pointed  bistoury,  or  tenotome, 
which  is  passed  beyond  the  coarctation,  so  as  to  divide  not  only 
the  diseased  portion,  but  also  about  one-half  of  an  inch  of  sound 
tissue  on  the  floor  of  the  urethra  behind  and  in  advance  of  it 

Fig.  145. 


Bistouri-Cacho. 


during  its  withdrawal.     A  convenient  little  instrument  for  the 
same  purpose  is  the  concealed  bistoury  of  Civiale,  sketched  in 


STRICTURE    OF    THE    URETHRA. 


481 


Fis. 


^g.  145.  It  consists  of  a  small  blade  which  may  Ijo  protruded 
from  its  sheath  by  pressing  upon  the  trigger,  after  the  instru- 
ment has  been  inserted,  the  extent  of 
the  incision  being  regulated  by  the 
screw  at  the  handle.  A  full-sized  coni- 
cal bougie  is  then  passed  to  separate  still 
farther  the  edges  of  the  rent,  and  hemor- 
rhage is  controlled  by  the  insertion  of  a 
small  pledget  of  lint,  confined  b}^  a  nar- 
roAv  strip  of  adhesive  plaster.  On  ac- 
count of  tlie  tcfndenc}^  to  recontraction 
at  this  localit}^  a  bougie  should  be 
passed  daily  until  cicatrization  is  com- 
pleted. 

In  the  remainder  of  tlie  canal,  the 
stricture  may  be  divided  from  behind 
forwards,  or  from  before  backwards. 
In  the  former  procedure,  which  is  the 
safer  and  more  reliable,  the  stricture 
must  previously  be  sufficiently  dilated 
to  admit  of  the  passage  of  an  instrument 
provided  with  a  bulb,  through  which, 
on  its  withdrawal,  the  location  of  the 
coarctation  is  clearly  defined,  and  its 
accurate  division  insured.  To  fulfil 
tliese  indications,  the  most  simple  and 
perfect  urethrotome  with  Avhich  I  am 
acquainted  is  that  devised  by  Dr.  S.  W. 
Gross,  and  represented  in  fig.  146.  It 
is  modelled  after  the  exploratory  bougie, 
and  the  bulb,  which  is  conoidal  in  its 
configuration,  carries  a  concealed  blade, 
which  may  be  protruded  to  the  extent 
of  one  millimetre  and  a  half  beyond  the 
level  of  the  bulb,  by  sliding  the  button 
at  the  proximal  extremity  of  the  stem 
of  the  instrument.  The  bulbs  themselves  vary  in 
size,  in  accordance  with  the  requirements  of  each 
individual  case,  the  smallest  corresponding  Avith  No.  10,  and  the 
stem  with  ISTo.  6.  In  the  larger  instruments,  the  stem  equals 
31 


Civiale's 
Uretlirotoine. 


Dr  S  W  Gross's 
Uiellii'utoiiie. 


482  STRICTURE    OF    THE    URETHRA. 

No.  9.  The  entire  leuirtli  of  the  contrivance  is  ten  inches  and  a 
half,  of  which  two  inches  are  taken  np  hy  the  handle  and  the  screw 
which  confines  the  stylet  carrying  the  hlade  on  its  retraction. 

In  the  instrument  of  Civiale,  fig.  147,  which  is  so  generally 
employed  for  retrograde  urethrotomy,  the  hulb,  in  consequence 
of  its  flattened,  olivary  shape,  and  the  absence  of  a  well-defined 
shoulder,  is  not  well  adapted  for  defining  a  stricture,  nor  does  it 
fill  and  stretch  the  urethra  immediately  behind  it.  The  blade, 
moreover,  projects  much  farther  than  there  is  any  necessity  for, 
unless  the  tissues  are  thick  and  resistant,  in  which  event,  its 
mechanism  is  applied  by  Dr.  Gross  to  his  acorn-headed  urethro- 
tome. 

The  stricture,  if  not  one  of  large  calibre,  having  been  dilated 
to  the  requisite  size,  and  its  length  determined  by  the  soft  explo- 
ratory bougie,  the  bulb  of  the  urethrotome  is  carried  beyond  it, 
its  passage  being  materially  assisted,  when  the  coarctation  is 
seated  far  back,  by  the  finger  in  the  rectum,  and  the  situation  of 
the  stricture  accurateh'  determined  by  advancing  the  bulb,  the 
projecting  shoulder  of  which  catches  against  its  posterior  face. 
The  penis  being  put  u])0n  the  stretch,  the  bulb  is  then  carried 
backwards,  the  object  being  to  divide  not  onh*  the  stricture, 
but  the  sound  tissues  for  half  an  inch  behind  and  anterior  to  it, 
when  the  blade  is  projected  and  the  parts  severed.  If  there  is 
much  resistance  on  the  withdrawal  of  the  instrument,  another 
incision  should  be  made  through  the  roof  of  the  urethra.  A 
steel  bougie,  of  a  size  adapted  to  restoring  the  urethra  to  its 
normal  calibre  at  the  diseased  part,  is  then  passed,  and  its  curve 
firmly  pressed  against  the  incision.  On  its  removal,  the  explora- 
tory bougie  is  inserted  with  the  view  of  detecting  any  uncut 
bands,  which,  if  present,  should  next  be  divided.  The  bladder 
having  been  emptied,  the  patient  is  put  to  bed,  and  a  full  dose 
of  quinine  and  morphia  exhibited. 

Dr.  Otis  has  devised  what  he  terms  a  dilating  urethrotome, 
fig.  148,  for  eft'ecting  the  complete  retrograde  division  of  coarc- 
tations, whether  seated  in  the  curved  or  straight  urethra.  The 
stricture  is  overstretched  by  the  separation  of  the  blades, 
whereby  it  is  rendered  salient,  and  divided  by  retracting  the 
guarded  knife,  which  runs  in  a  groove  along  the  upper  blade. 
The  only  objection  to  tliis  instrument  is  that  the  position  of  the 
stricture  has  to  be  ascertained  by  previous  measurement,  which. 


STRICTURE    OF    THE    URETHRA.  483 

on  account  of  the  mobility  of  the  urethra,  is  a  most  nncertain 
guide.  The  addition  of  a  small  bulb  at  the  vesical  extremity, 

Fig.  148.  Fig.  149.  Fig.  150. 


I 


i 


Author's  rie;lirol<>ine. 


Trulafs   Uiethiotome. 


for  concealing  the  knife,  and  accurately 
defining  the  coarctation,  would  leave  no- 
thing to  be  desired  in  the  way  of  a  cutting 
instrument. 

Incision  from  before  backwards  may  be 
effected  with  the  contrivance  represented 
in  fig.  149,  which  I  have  for  many  years  been  in  the  habit  of 
employing,  or  with  that  of  Trdlat,  fig.  150,  the  latter  possessing 


Dr.  Otis's  Dilating  Urethrotome. 


484 


STRICTUEE    OF    THE    URETHRA. 


the  additional  advantage  of  cnttiniy  in  an  opposite  direction,  on 
its  witlidrawal,  if  such  a  procedure  be  deemed  necessary.  What- 
ever instrument  may  he  selected,  it  is  indispensable  to  safe 
practice  that  the  vesical  extremity,  or  gnide,  be  fairly  passed 
througli  the  stricture  before  the  blade  is  protruded.  The  opera- 
tion is  useful  in  tight  or  resilient  strictures  within  the  first  four 
inches  of  the  canal ;  but  the  general  adoption  of  rupture  has 
made  its  employment  rare.  It  may  be  remarked  that  the  in- 
Pj^  j-j  struments  found  in  the  shops  are  unwieldy 

from  their  length,  which  should  not  exceed 
nine  inches. 

The  subsequent  treatment  is  conducted 
in  accordance  with  the  rules  laid  down  in 
the  section  on  rupture.  If  all  resisting 
bauds  liave  been  thoroughly  divided,  and  a 
bougie  of  the  size  of  the  natural  calibre  of 
the  urethra  slips  easily,  by  its  own  weight, 
into  the  bladder,  without  meeting  with  the 
slightest  impediment  to  its  insertion  or 
withdrawal,  after  the  wound  has  healed,  I 
have  every  reason  to  believe  that  recontrac- 
tion  need  not  be  feared,  and  that  the  subse- 
quent methodical  use  of  the  steel  bougie 
may  be  dispensed  with,  except  at  long  in- 
tervals, as  a  matter  of  precaution. 

4.  External  Urethrotomy. — The  division 
of  stricture  from  the  perineum,  includes  two 
eutireh'  distinct  operations,  that  of  external 
uretlirotomy,  conducted  upon  a  guide,  and 
perineal  section,  or  external  urethrotomy, 
without  a  guide.  In  the  former  procedure, 
the  urethra  is  permeable,  while,  in  the  latter, 
it  is  impassable  b}'  an  instrument. 

a.  In  performing  external  urethrotomy  on 
a  guide,  an  operation  which  was  originally 
described,  in  1844,  by  Mr.  Syme  under  the 
appellation  of  "  external  division,"  the  an- 
aesthetized patient  is  placed  in  the  lithotomy 
position,  and  Syme's  staff,  the  construction 
symes staff.  of  wliicli  is  represented  in  tig.  151,  is  passed 


STEICTITRE    OF    TPIE    URETHRA.  485 

through,  and  its  shoulder,  which  corresponds  to  the  point  at 
which  the  small  vesical  extremity  leaves  the  shaft,  pressed 
against  the  face  of  the  stricture  by  an  assistant.  The  parts  being 
shaved,  the  nates  are  brought  close  to  the  edge  of  the  table,  and 
the  surgeon,  sitting  on  a  low  chair,  or  resting  npon  one  knee, 
makes  his  incisious  exactly  in  the  middle  line  of  the  perineum. 
Having  divided  the  superficial  structures,  he  feels  for  the 
shoulder  of  the  staff,  and  taking  that  as  a  guide  to  the  position 
of  the  stricture,  enters  the  knife,  the  back  of  which  is  turned 
towards  the  anus,  in  the  groove,  an  inch  posterior  to  the 
shoulder  of  the  instrument,  and  cuts  as  far  forwards  as  the 
termination  of  the  groove  in  the  shaft.  In  this  step  of  the 
operation  he  controls  the  staff  with  his  left  hand.  The  stricture, 
along  with  half  an  inch  of  the  sound  urethra  in  front  and  behind, 
having  been  completely  divided,  the  shoulder  of  the  staif  may 
easily  be  carried  onwards.  Instead  of  proceeding  in  this  manner, 
the  operator  may  open  the  urethra  in  front  of  the  shoulder  of 
the  instrument,  and  divide  the  contracted  tissues  from  before 
backwards.  The  whole  wound  does  not  exceed  an  inch  and 
a  half,  and  occasionally  it  need  not  even  be  so  large.  Care 
should  be  taken  not  to  divide  the  deep  fascia  of  the  perineum, 
and  to  keep  as  much  as  possible  in  the  middle  line,  so  that  the 
bulb  will  be  opened  through  its  septum,  whereby  the  risks  of 
hemorrhage  are  reduced  to  a  minimum. 

A  modification  of  this  operation,  and  one  which  is  said  by 
Mr.  Teevan,'  and  others,  to  be  particularly  applicable  to  cases 
uncomplicated  by  abscesses  or  fistules,  is  that  known  as  sub- 
cutaneous urethrotomy,  in  which  the  stricture  is  divided  on  a 
grooved  staflF,  with  a  straight,  narrow-bladed  knife,  the  external 
opening  being  confined  to  a  mere  puncture.  This  method  also 
originated  with  Mr.  Syme ;  but  I  am  not  aware  that  it  is  prac- 
tised out  of  Great  Britain. 

In  view  of  the  danger  of  the  formation  of  a  false  passage  by 
the  delicate  inflexible  staft'  of  Mr.  Syme,  or  of  its  entering  a  pre- 
existing false  route,  through  which  the  urethra  would  escape 
division.  Dr.  Gouley^  substitutes  for  it  a  filiform  whalebone 
bougie,  which  being  passed  into  the  bladder,  is  utilized  as  a 

'  Trans.  Clin.  Soc.  of  London,  vol.  viii.,  1875,  p.  65. 
2  Diseases  of  the  Urinary  Organs,  1873,  p.  122, 


486 


STRICTURE    OF    THE    URETHRA. 


guide  for  his  grooved  catlieter-staft".  The  peculiarity  of  this 
instrument  consists,  as  shown  in  fig.  152,  in  the  bridging  over 
of  its  terminal  quarter  of  an  inch,  by  whicli 
the  groove  is  converted  into  a  canal,  the  bridged 
portion  itself  being  also  grooved.  It  is  intro- 
duced by  passing  through  the  canal  the  free 
end  of  the  bougie,  which  guides  it  onwards 
until  its  beak  comes  in  contact  with  the  stric- 
ture. The  superficial  incisions  being  made  as 
in  the  ordinary  procedure,  the  urethra  is  opened 
on  the  bridged  portion  of  the  staff,  the  latter  of 
which  is  then  slightly  withdrawn  so  as  to  expose 
the  whalebone  guide,  along  which  a  straight 
probe-pointed  bistoury  divides  the  stricture  and 
half  an  inch  of  the  urethra  behind  it.  The 
operation  is  completed  hy  introducing  the  staff, 
still  supported  by  the  guide,  into  the  bladder. 
Whichever  mode  of  operating  may  be  adopted, 
it  is  of  the  last  im[iortance,  after  the  stricture  is 
divided,  to  pass  the  exploratory  bougie,  aided,  if 
it  be  found  necessary,  by  a  broad  grooved  director, 
carried  into  the  bladder  through  the  wound, 
with  the  view  of  detecting  any  remaining  bands, 
which  if  uncut,  would  render  the  whole  proce- 
dure, at  the  best,  merely  palliative,  instead  of 
curative.  The  retention  of  a  catheter  for  forty- 
eight  hours,  as  advised  by  some  surgeons,  is  not 
required,  unless  it  should  become  necessary  to 
plug  the  wound  on  account  of  hemorrhage. 

There  are  two  most  important  circumstances 
which  should  claim  attention  after  every  opera- 
tion of  this  kind ;  the  fi^rst  is,  to  regulate  the 
general  health,  and  the  second,  to  insist  upon 
the  frequent  use  of  the  steel  bougie,  in  order  that  the  advantages 
gained  may  not  be  lost,  or,  what  amounts  to  the  same  thing, 
that  the  stricture  may  not  be  reproduced.  The  same  rules  that 
govern  the  surgeon  in  the  treatment  of  his  patient  after  the 
operation  by  dilatation  or  incision  are  applicable  here,  and 
should  always  be  most  scrupulously  enforced.  The  instrument 
should  be  passed,  at  first,  at  least  once  every  third  or  fourth  day, 


Oouley"s  Grooved 
and  TuDuelled  Caiiieter 
Staff. 


STRICTURE    OF    THE    URETHRA. 


487 


Fiff.    153. 


and  afterwards  once  a  week,  then  once  a  fortnight,  and  finally 
once  a  month,  until  all  dang-er  of  relapse  is  over,  Ilorsehack 
exercise,  sexual  indulgence,  and  stimulating  food  and  drink 
should  be  carefully  avoided  ;  the  bowels  should  be  constantly 
maintained  in  a  soluble  state,  and  the  strictest  attention  should 
be  paid  to  the  secretions. 

The  results  of  this  operation,  as  far  as  they  are  known,  are 
eminently  encouraging,  exhibiting  as  they  do,  a  most  extra- 
ordinary array  of  success.  Of  108  cases  in  the  hands  of  Mr. 
Syme,  up  to  1863,  two  only  had  ended  fatally;  and  of  219  cases 
collected  by  Sir  Henry  Thompson,  there  was  a  mortality  of  15, 
so  that  the  death-rate  may  be  placed  at  5.16  per  cent.  The 
most  fruitful  source  of  death  is  pyemia. 

The  procedure  should  be  reserved  for  extensive  traumatic 
strictures,  and  for  cases  complicated  by  great  induration  ftnd 
listules.  Relapses  will  be  most  likely  to  follow  when  there 
has  been  neglect  in  the  after-treatment,  and  in  old,  worn-out, 
chronic  cases,  with  a  riddled  perineun  and  a  diseased 
condition  of  the  urinary  organs. 

3.  External  perineal  urethrotomy,  without  a  guide, 
perineal  section,  or  the  button-hole  operation,  as  the 
second  procedure  is  variously  termed,  dates  back  to 
1652,  when  it  was  iirst  performed  by  Molins,  an  Eng- 
lish surgeon.  The  etherized  patient  being  placed  in 
the  lithotomy  position,  and  a  grooved  statf,  which  is 
confided  to  an  assistant,  being  passed  down  to  the 
stricture,  the  surgeon  opens  the  urethra  by  a  free 
incision  in  the  middle  line,  in  front  of  the  coarctation. 
The  sides  of  the  wound  are  then  widely  separated  by 
tenacula  or  loops  of  waxed  silk,  so  as  to  expose  fully 
the  face  of  the  contraction,  when  attempts  are  made 
to  insert  a  small,  flexible,  metallic  grooved  director, 
fig.  153,  or  a  filiform  guide  into  its  opening,  upon 
which  the  necessary  division  may  be  efiected  as  in 
the  preceding  operation.  Failing  in  these  efibrts,  the 
surgeon  carefully  and  patiently  dissects  through  the 
thickenened  and  indurated  tissues  until  the  urethra  is  ""''^'^l^'' 
opened  below  the  stricture,  after  which  a  full-sized 
bougie  is  passed  into  the  bladder,  and  the  subsequent  treatment 
conducted  upon  general  princi[iles. 


488  STRICTURE    OF    THE    URETHRA. 

This  operation  wliicli  is  only  adapted  to  impassable  strictures, 
requires  the  most  consummate  skill  for  its  successful  execution, 
and  should  never  be  undertaken  unless  the  surgeon  has  a  pro- 
found knowledge  of  the  anatomy  of  the  parts,  and  a  thorough 
acquaintance  with  the  use  of  instruments.  Unless  it  is  compli- 
cated by  advanced  disease  of  the  kidneys  or  bladder,  it  is  not 
very  lethal.  I  have  myself  performed  perineal  section  26  times 
with  only  one  death,  and  of  -43  cases,  from  the  practice  of 
Jameson,  Rogers,  Warrren,  and  Gouley,  all  were  successful.  In 
the  hands  of  Gernian  and  French  operators,  however,  the  results 
are  not  so  good,  since  of  35  cases  collected  by  Boeckel,  8,  or 
22.85  per  cent.,  were  fatal. 

Stricture  of  the  Urethra  in  the  Female. — Stricture  of  the 
urethra  in  the  female  is  exceedingly  infrequent.  As  in  the 
male,  it  may  arise  from  gonorrhea  or  chancre ;  but  it  is  most 
commonly  caused  by  contusion,  the  effect  of  the  pressure  of  the 
child's  head  in  parturition,  or  the  maladroit  use  of  the  forceps. 

The  obstruction  may  occur  at  any  point  of  the  canal,  but  in 
most  instances  it  is  seated  just  behind  the  external  orifice,  where 
it  presents  itself  in  the  form  of  a  narrow,  annular  constriction. 
Occasionally  the  stricture  is  several  lines  in  length,  and  in  a 
few  rare  instances,  one  of  which  came  under  my  own  observation, 
it  has  been  found  to  occupy  the  entire  canal  from  one  extremity 
to  the  other. 

The  sj-mptoms  and  effects,  local  and  general,  do  not  differ 
from  those  of  stricture  in  the  other  sex,  and  they  do  not,  there- 
fore, require  any  particular  notice.  The  treatment  is  also 
similar,  the  proper  remedy  being  internal  urethrotomy,  practised 
with  a  tenotome  and  grooved  director.  Dr.  Xewman,^  of  Xew 
York,  has  recently  advocated  the  electrolytic  treatment  of 
stricture  in  the  female ;  but  from  the  unsatisfactory  results 
afforded  by  galvanism  in  the  same  affection  in  the  male,  it  is 
scarcely  probable  that  this  measure  will  command  more  than 
passing  attention. 

'  American  Jouru.  of  Med.  Sci.,  Oct.  1875,  p.  433. 


CHAPTER    III. 

INJURIOUS  EFFECTS  OF  OPERATIONS  ON  THE  URETHRA. 

The  different  methods  of  treating  stricture,  described  in  the 
preceding  chapter,  are  all  liable,  hoAvever  carefully  or  judiciously 
conducted,  to  be  followed  by  very  serious  and  even  fatal  con- 
sequences. It  is  well  known  that  patients,  especially  such  as 
are  very  nervous  and  irritable,  occasionally  suffer  most  violently 
from  the  most  trifling  operations  upon  the  urinary  organs,  the 
mere  passage  of  a  bougie,  sound,  or  catheter  inducing  violent 
rigors,  excessive  prostration,  and  other  unjileasant  symptoms. 
Indeed,  a  large  number  of  cases  are  upon  record,  in  which  death 
was  produced  by  this  cause,  even  Avlien  there  was  no  severe 
disease;  and  there  are  few^  practitioners,  of  any  experience  in 
this  branch  of  surgery,  who  have  not  witnessed  the  distress, 
local  and  constitutional,  which  healthy  persons  often  suffer  from 
an  attempt  to  pass  an  instrument  into  the  bladder.  The  sensi- 
bility of  the  urethra  is  naturally  very  great,  and  hence  it  is  not 
surprising  that  the  contact  of  a  bougie,  however  slight,  should 
occasionally  be  folloAved  by  great  pain  in  the  part,  nervous  pros- 
tration, and  other  disagreeable  effects.  Fortunately,  all  persons 
are  not  constituted  alike  in  this  particular,  otherwise  these 
effects  would  be  of  much  more  frequent  occurrence  than  they 
are  found  to  be  in  practice.  The  treatment  of  stricture,  how- 
ever, is  peculiarly  liable  to  be  attended  witli  rigors,  urethral 
fever,  supjiression  of  urine,  and  pyemia,  owing  to  the  fact  that 
many,  if  not  most  of  the  subjects  of  this  disease,  are  remarkably 
prone  to  renal  and  vesical  disorders,  and,  therefore,  easily  affected 
by  the  most  trivial  operations  performed  for  its  relief. 

a.  Urethral  Fever. — Unless  particular  attention  has  been  paid 
to  the  preliminary  treatment,  both  local  and  general,  operations 
upon  the  urethra  are  liable  to  be  followed  by  a  peculiar  reaction, 
as  denoted  by  the  occurrence  of  rigors,  wdth  or  without  subse- 
quent febrile  action,  to  which  the  term  urethral  fever  is  commonly 
applied.  A  fit  of  shivering  should  never  be  overlooked,  since 
it  is  often  a  premonitory  sign  of  uremic  accidents  or  pyemia. 


490      INJURIOUS    EFFECTS    OF    OPERATIONS    ON    URETHRA. 

and  no  reliable  conclusion  can  be  drawn  from  the  interval  be- 
tween the  operation  and  its  occurrence,  as  to  whether  it  merely 
foreshadows  reflex  or  morbid  reaction. 

Apart  from  pyemia,  rigors  denote  at  least  three  essentially 
ditferent  conditions,  or  have  a  threefold  origin.  In  the  first,  and 
mildest,  class  of  cases,  temporary  and  irregular  chilly  sensations 
indicate  a  nervous,  irritable  state  of  the  system.  In  the  second 
class  of  cases,  an  attack  of  shivering  comes  on  usually  within  the 
first  twenty-four  hours,  and  is  rarely  delayed  beyond  the  second 
day.  It  is  frequently  due  to  tying  in  a  catheter,  and  is  not  un- 
commonly coincident  with  the  first  passage  of  the  urine  over 
the  sensitive,  incised,  or  ruptured  mucous  membrane  of  the  ure- 
thra. The  chill  is  often  violent  and  prolonged,  and  the  tem- 
perature rises  from  two  to  eight  degrees  during  its  continuance. 
It  is  followed  by  fever  and  profuse  sweating,  and  leaves  the 
patient  in  an  exhausted  state.  The  paroxysm  is  usually'  single ; 
the  symptoms  abate  with  more  or  less  rapidity;  and  the  patient 
soon  regains  his  strength.  This  is  urethral  fever,  properly  so 
called,  and  corresponds  with  traumatic  or  surgical  fever.  In  the 
third  class  of  cases,  the  rigors,  which  come  on  within  a  few  hours, 
are  rapidly  succeeded  by  signs  of  suppression  of  urine  and  uremic 
intoxication,  such  as  headache,  vomiting,  diarrhoea,  drowsiness 
or  somnolence,  thirst,  scanty  urine,  pain  in  the  region  of  the 
kidneys,  lowered  temperature,  feeble  pulse,  and  urinous  odor  of 
the  secretions  and  excretions.  These  symptoms  may  disappear 
in  a  few  days  without  farther  trouble;  or  they  may  be  succeeded 
by  convulsions,  coma,  and  death.  In  rare  instances,  they  seem 
to  culminate  with  great  rapidity,  and  the  case  terminates  fatally 
in  a  few  hours. 

The  mortality  after  operations  on  the  urethra  is  generally  due 
to  chronic  Bright's  disease  or  pyelitis.  Hence,  before  entering 
upon  any  plan  of  treatment,  the  prudent  surgeon  will  test  the 
urine  for  pus,  albumen,  and  tube-casts,  the  presence  of  which 
must,  of  necessity,  modify  his  views  in  regard  to  the  propriety 
of  operative  procedures.  The  occurrence  of  a  chill,  or  succession 
of  chills,  and  faintness,  followed  by  fever  and  scanty  urine,  after 
each  passage  of  an  instrument,  are  signs  wdiich  should  awaken 
suspicion  of  chronic  disorder  of  the  kidneys.  There  is  certainly 
no  connection  between  the  rigors  and  the  size  or  location  of  the 
stricture,  but  they  appear  to  be  dependent,  in  the  large  majority 


IXJUllIOUS    EFFECTS    OF    OPERATIONS    ON    URETHRA.      491 

of  cases,  upon  chronic  Bright's  disease,  and  the  explosion  of  this 
extremely  dangerous  complication.  In  one  form  of  that  affection 
— contracted  granular  kidney — neither  tube-casts  nor  albumen 
may  be  present  in  the  urine  to  indicate  latent  or  insidious  renal 
trouble,  so  that  it  is  hy  no  means  possible  to  determine  whether 
rigoi's  will  occur  or  not.' 

Much  may  he  done  in  the  way  of  preventing  the  unpleasant 
nervous  symptoms  which  occasionally  succeed  operations  upon 
the  urethra  by  judicious  preparatory  treatment,  in  accordance 
with  the  principles  already  laid  down  at  page  470.  Of  the 
general  remedies,  which  appear  to  exert  some  influence  upon  the 
prevention  of  a  chill,  quinine  is  the  most  efhcacious,  the  system 
being  brought  gently  under  its  action  several  days  previous  to 
the  performance  of  an  operation.  I  am  in  the  habit  of  admin- 
istering ten  grains  of  the  alkaloid  immediately  before  the  ope- 
ration, which  should  be  done  under  chloroform  or  ether,  and 
injecting  one- third  of  a  grain  of  morphia  under  the  skin  at  its 
conclusion.  On  no  account  should  the  patient  be  permitted  to 
leave  his  bed  before  the  expiration  of  two  days. 

'  In  Ins  wards  at  the  Pliiladclpliia  Hospital,  during  the  past  two  winters,  the 
editor  had  the  misfortune  to  lose  three  patients  after  operations  for  stricture,  in 
none  of  whom  did  appropriate  tests  detect  the  presence  of  tube-casts  or  albumen 
in  the  urine,  and  in  wliom  the  coarctations  were  of  large  calibre.  In  a  man  of 
54,  there  were  two  strictures  of  a  calibre  of  16,  located  respectively  at  3"  and 
5"  from  the  external  meatus.  Their  internal  division  was  followed,  in  three 
hours,  by  a  violent  chill,  which,  in  its  turn,  w^as  succeeded  by  stupor  and  a  very 
feeble  pulse,  and  by  another  chill  in  twenty -four  hours.  The  urine  was  scanty, 
and  its  secretion  was  totally  suppressed  for  fourteen  hours  before  the  fatal  issue. 
After  the  second  rigor,  there  were  lieadache,  vomiting,  diarrhcea,  and  pain  in  the 
hypogastrium  ;  the  skin  was  cold  and  moist,  and  the  countenance  presented  a 
dusky  purple  hue.  Death  ensued,  in  a  state  of  profound  coma,  in  forty-eight 
liours  from  the  date  of  the  operation.  Both  kidneys  were  contracted  and 
granular.  In  the  second  case,  occurring  in  a  man  of  39,  two  strictures,  seated  1  :|" 
and  23"  from  the  meatus,  and  of  a  calibre  of  16,  were  divided.  A  chill  occurred 
in  nineteen  hours,  and  was  followed  by  symptoms  of  uremic  intoxication  and 
death  on  the  fourth  day.  The  condition  of  the  kidneys  was  precisely  similar  to 
that  in  the  preceding  instance.  In  the  third  case,  a  man  of  61  was  subjected 
to  internal  urethrotomy  for  two  strictures,  of  which  the  first,  of  the  calibre  of 
17,  was  seated  4^"  from  the  meatus,  and  the  second,  of  the  calibre  of  14,  6^" 
from  the  external  orifice.  He  had  a  violent  chill  in  twenty-four  liours,  aud  died 
from  suppression  of  urine  on  the  fifth  day.  The  right  kidney  was  granular  and 
contracted,  and  weighed  less  than  one  ounce,  while  the  left  kidney  was  enlarged, 
smooth,  and  white.  A  little  urine,  found  in  the  bladder,  contained  casts,  epi- 
thelial cells,  and  albumen,  which  could  not  be  detected  before  the  operation. 


492      INJUKIOUS    EFFECTS    OF    OPERATIONS    ON    URETHRA. 

Rigors  of  the  nervous  type  readily  yield  to  a  hot  brandy  toddy 
and  rest  in  bed.  When  the  chill  is  violent  or  prolonged,  its 
severity  may  be  moderated,  and  the  subsequent  hot  stage  be 
shortened,  by  the  administration  of  a  drachm  of  chloroform  in 
emulsion.  On  its  disappearance,  a  full  dose  of  morphia  will  do 
much  to  make  the  patient  comfortable,  and  subdue  nervous  and 
vascular  excitement.  Promptness  of  action  is  of  the  greatest 
importance,  when  uremic  symptoms  manifest  themselves,  the 
great  indications  being  to  maintain  diaphoresis  by  Dover's 
powder,  solution  of  acetate  of  ammonia,  and  the  hot-air  bath; 
to  secure  the  activity  of  the  intestines  by  saline  cathartics;  and 
aid  in  restoring  the  functions  of  the  kidneys  by  dry  cupping 
and  hot  fomentations.  Convulsions  may  be  controlled  by  the 
inhalation  of  chloroform,  and  coma  be  relieved  by  venesection, 
if  the  patient's  general  condition  be  fair,  and  the  comatose  symp- 
toms come  on  rapidly. 

S.  Pyemia. — In  another  class  of  cases,  a  still  more  serious  eftect 
is  occasionally  witnessed,  as  the  result  of  operations  upon  the 
urethra.  I  allude  to  the  formation  of  matter  in  the  joints,  mus- 
cles, veins,  connective  tissue,  and  other  structures.  The  patient 
is  seized  with  rigors,  which,  after  having  continued  for  a  variable 
period,  are  followed  by  profuse  sweats  and  a  sense  of  excessive 
prostration.  The  disease  in  fact,  at  its  commencement,  frequently 
resembles  an  attack  of  ordinary  intermittent  fever,  or  the  parox- 
ysms sometimes  recur  twice  or  thrice  in  the  twenty-four  hours. 
Occasionally,  again,  it  closely  simulates  an  attack  of  rheumatism, 
especially  when  there  is  intense  pain  in  the  joints  and  limbs.  In 
whatever  manner  it  makes  its  appearance,  the  case  soon  assumes 
a  most  threatening  character.  The  pulse  becomes  small,  fre- 
quent, and  feeble,  the  appetite  declines,  the  stomach  is  irritable, 
the  bowels  are  costive,  the  urine  is  scanty  and  high-colored,  and 
there  is  excessive  thirst,  with  constant  restlessness  and  great 
anxiety  of  mind.  Delirium  and  stupor  generally  set  in  at  an 
early  period,  and  constitute  prominent  phenomena  of  the  com- 
plaint. 

The  symptoms  now  described  may  come  on  within  a  few  houre 
after  the  operation,  of  which  they  are  the  consequence ;  but,  in 
general,  they  do  not  show  themselves  under  three  or  four  days, 
at  all  events  not  with  any  degree  of  severity.  They  soon  assume 
a  typhoid  character,  and  few  patients  survive  beyond  ten  days 


INJUEIOUS    EFFECTS    OF    OPERATIONS    ON    URETHRA.      493 

or  a  fortniglit.  The  formation  of  matter  is  usually  preceded  and 
accompanied  by  an  erysipelatous  blush  of  the  skin,  by  exquisite 
tenderness  of  the  part,  and  by  great  impediment  of  motion.  The 
pus,  which  often  exists  in  considerable  quantities,  either  as  a 
simple  collection,  or  in  the  form  of  distinct  abscesses,  is 
commonl}'  of  a  sanious  and  unhealthy  character,  and  sometimes 
highly  fetid.  The  structures  which  are  most  liable  to  suffer 
are  the  joints,  as  the  knee,  ankle,  hip,  and  shoulder,  the  mus- 
cles and  connective  tissue  of  the  extremities,  the  perineum,  and 
scrotum,  the  connective  tissue  and  veins  of  the  pelvis,  the  liver, 
and  spleen.  The  number  of  abscesses  is  sometimes  very  great, 
and,  when  this  is  the  case,  they  are  always  proportionately 
small. 

Pyemia  does  not  always  run  the  acute  course  here  spoken  of. 
In  some  cases,  as  pointed  out  b}'  Sir  James  Paget,^  it  is  decidedly 
chronic  and  even  relapsing,  extending  over  weeks  and  months. 
Its  progress  is  much  slower,  and  its  results  far  less  fatal,  than 
those  of  the  acute  form  of  the  affection,  from  which  it  also  differs 
in  the  more  frequent  occurrence  of  abscesses  in  the  limbs  and 
trunk  than  in  the  internal  organs.  . 

A  peculiar  and  localized  form  of  pyemia  has  been  described 
by  Dr.  W.  H.  Dickinson,^  and  is  sometimes  spoken  of  as  "surgical 
kidney."'  It  consists  of  the  formation  of  abscesses,  along  the 
course  of  the  veins,  in  the  renal  interlobular  connective  tissue, 
which  is  congested  and  friable,  while  the  straight  tubes  are 
dilated,  and  their  accompanying  vessels  distended  or  occupied 
by  emboli.  "  The  disorder  has  its  origin  in  the  regurgitation 
of  urine  charged  with  morbific  deposits.  This  occupies  and 
generally  distends  the  straight  ducts,  and  thence  enters  the 
neighboring  bloodvessels,  and  charges  them  with  an  infection 
resembling  in  its  results  that  of  pyemia.  This  is  distributed 
by  the  veins  to  the  rest  of  the  gland,  sowing  abscesses  in  their 
course,  and  ultimately  causing  constitutional  symptoms  analo- 
gous to  those  of  pyemia  when  otherwise  derived."  The  symp- 
toms, which  are  always  associated  with  those  of  iiolvic  and 
vesical  inflammation,  are  those  of  blood-poisoning,  and  boar  a 
general  resemblance  to  those  of  pyemia,  although  other  organs 

'  Clinical  Lectures  and  Essays,  p.  155,  London,  1875. 
2  London  Lancet,  March  8,  1873. 


494      INJURIOUS    EFFECTS    OF    OPERATIOXS    ON    URETHRA. 

or  tissues  seldom  take  part  in  the  suppuration.  The  aftection 
usually  ends  fatally  within  three  weeks,  and  is,  next  to  Bright's 
disease,  the  most  counuon  cause  of  death  after  operations  upon 
the  urethra. 

The  treatment  of  pyemic  symptoms  is  sustaining,  stimulant, 
and  soothing;  brandy,  good  food,  fresh  air,  careful  nui'sing,  qui- 
nine, and  opium,  being  the  remedies  upon  which  the  greatest 
reliance  is  to  he  placed.  When  there  is  disseminated  suppura- 
tion of  the  kidneys,  the  ammoniacal  and  putrid  decomposition 
of  the  urine  must  be  prevented,  by  preserving  the  natural 
acidity  of  that  excretion.  Arthritic  symptoms,  and  the  forma- 
tion of  matter  in  the  connective  tissue,  joints,  muscles,  viscera, 
and  veins,  must  be  met  by  leeches,  blisters,  iodine,  and  fomenta- 
tions, medicated  with  acetate  of  lead  and  laudanum,  and  by  the 
internal  use  of  calomel  and  opium.  Superficial  abscesses  must 
he  opened  by  early  and  free  incisions. 


CHATTER  IV. 

HEMORRHAGE  OF  THE  URETHRA. 

Hemorrhage  of  the  urethra,  although  not  veiy  conimou,  is 
always  alarming  to  the  patient  and  a  source  of  emharrassment 
to  the  practitioner.  It  occurs  under  two  varieties  of  forms,  the 
spontaneous  and  the  traumatic,  of  which  the  latter  is  by  far  the 
more  frequent.  When  the  mucous  membrane  is  in  a  varicose 
condition,  or  abnormally  soft  and  vascular,  as  it  sometimes  is  in 
consequence  of  protracted  congestion,  the  slightest  cause  is  fre- 
quently sufficient  to  bring  on  a  discharge  of  blood.  Under  such 
circumstances,  it  is  hardly  possible  to  introduce  a  catheter,  a 
bougie,  or  a  sound,  without  inducing  some  degree  of  bleeding. 

The  spontaneous  form  is  most  common  in  old  and  middle-aged 
persons,  who  liave  led  a  life  of  irregularity  and  debauch,  and 
labor  under  habitual  relaxation  of  the  lining  membrane  of  the 
urethra.  In  such  individuals,  the  slightest  erection,  straining 
at  stool,  or  horseback  exercise,  is  sufficient  to  bring  on  an  attack. 
Frequently,  indeed,  it  makes  its  appearance  without  any  assign- 
able cause  whatever,  perhaps  while  the  patient  is  Ij'ing  in  bed, 
or  walking  about.  I  am  occasionally  in  attendance  upon  a 
gentleman,  about  thirty-six  years  of  age,  who  has  had  repeated 
discharges  of  this  kind,  without  having  been  able,  in  a  solitary 
instance,  to  trace  them  to  any  particular  agencj'.  The  discharge, 
in  him,  is  usually  of  a  dark  modena  color,  small  in  quantity,  and 
of  short  duration.  Spontaneous  hemorrhage  here,  as  elsewhere, 
is  generally  the  result  of  a  process  of  exhalation,  and  proceeds, 
from  the  prostatic  portioji  of  the  canal. 

Traumatic  hemorrhage  arises  from  various  causes.  Most 
frequently,  it  depends  upon  violence  inflicted  upon  the  urethra 
by  the  passage  or  lodgment  of  a  urinary  concretion,  the  intro- 
duction of  an  instrument,  as  a  catheter  or  bougie,  or  an  attempt 
to  force  a  stricture.  It  is  a  very  common  consequence  of  injury 
of  the  perineum;  and  it  often  follows  the  operation  of  cauteri- 
zation. Hemorrhage  of  the  urethra  occasionally  complicates 
the  acute  sta^e  of  gonorrhcea  as  the  result  of  a  rupture  of  some 


496  HEMORRHArxK    OF    THE    URETHRA. 

of  the  vessels  of  the  liuins^  membrane  from  clionlce,  or  the  a<?t 
of  coition.  A  friglitful  and  even  fatal  hemorrhage  has  occasion- 
ally been  produced  by  masturbation.  It  may  also  be  caused  by 
ulceration,  or  the  presence  of  a  chancre. 

The  quantity  of  tlio  effused  blood  varies  from  a  few  drops  to 
several  ounces.  Although  it  is  generally  greatest  in  cases  of 
laceration  and  ulcerative  perforation  of  the  tube,  it  is  sometimes 
not  less  abundant  when  it  has  its  source  in  a  slight  abrasion  of 
the  lining  membrane.  The  most  abundant  hemorrhages  usually 
proceed  from  the  posterior  part  of  the  urethra,  probably  on 
account  of  the  greater  vascularity  there,  both  of  the  mucous 
tissue  and  of  the  surrounding  structures.  It  is  not  often  that 
the  bleeding,  under  any  circumstances,  is  very  copious,  or  that 
the  blood  issues  rapidly,  or  in  a  full  round  stream.  I  have,  how- 
ever, seen  several  cases  in  wdiich  the  hemorrhage  was  so  great 
as  to  produce  serious  exhaustion,  and  where,  if  it  had  not  been 
promptly  arrested,  it  might  have  terminated  fatally. 

The  color  of  the  effused  fluid  varies  from  bright  scarlet  to 
black,  or  modena.  In  spontaneous  hemorrhage,  it  is  generally, 
at  least  according  to  m\'  own  experience,  of  a  venous  complexion : 
whereas,  in  the  traumatic  form,  it  is  commonly  of  an  arterial 
hue.  Contact  Avith  the  urine  always  renders  it  preternaturally 
dark. 

When  the  hemorrhage  is  caused  by  violence,  and  has  its 
source  high  up  in  the  urethra,  the  blood  may  regurgitate  into 
the  bladder,  where,  from  its  contact  with  the  urine,  it  soon 
coagulates,  and  often  leads  to  retention.  When,  on  the  contrary, 
it  has  its  rise  in  the  anterior  portion  of  the  canal,  the  fluid  gene- 
rally escapes  externally,  either  in  a  slow,  trickling  manner,  or 
in  a  tolerably  full  stream.  Sometimes  the  blood  coagulates  in 
the  urethra,  forming  a  long,  cjdindrical  plug,  accurately  repre- 
senting the  size  and  the  shape  of  the  canal,  and  of  sufficient 
firmness  to  be  pulled  away  without  breaking. 

Bleeding  of  the  urethra  seldom  requires  surgical  interference; 
in  most  cases  it  ceases  spontaneously,  or  is  easily  arrested  by 
repose  in  the  horizontal  posture  upon  a  hair  mattress,  iced 
drinks,  and  pressure,  for  a  few  minutes,  upon  the  perineum, 
direct!}^  opposite  to  the  part  from  Avliich  the  blood  proceeds. 
This  may  be  made  either  with  the  finger,  or  by  means  of  a 
twisted  towel,  rolled  up  and  applied  firmly  against  the  canal. 


HEMOERHAGE    OF    THE    URETHRA.  497 

111  employing  pressure,  it  is  a  matter  of  great  moment  that  it 
be  made  properlj^,  otherwise  it  will  nf)t  onl}'-  be  useless,  but 
decidedl}'  injurious.  It  is  not  always  easy  to  hit  the  precise 
spot  from  which  the  blood  issues;  hence  the  finger  must  be 
moved  about  from  one  part  to  another  until  the  object  is 
attained.  If  the  pressure  be  applied  in  front  of  the  seat  of  the 
hemorrhage,  there  is  great  probability  that  it  will  continue,  and 
that  the  blood  will  pass  back  into  the  bladder,  constituting  thus 
a  case  of  concealed  hemorrhage,  similar  to  that  which  is  occa- 
sionally met  with  in  the  uterus.  Such  an  occurrence  might 
not  onl}'  prove  dangerous,  but  fatal.  On  the  other  hand,  the 
pressure  must  not  be  made  behind  the  affected  part,  for  this 
proceeding,  although  not  attended  with  the  same  risk,  would 
be  equall}'  futile.  The  course  which  I  generally  pursue  is,  to 
place  the  finger  upon  the  part  from  which  the  blood  is  supposed 
to  proceed ;  holding  it  there  for  a  few  seconds,  I  ascertain 
whether  it  arrests  the  bleeding ;  if  it  do,  I  remove  it,  and  apply 
it  a  little  farther  back  ;  if  the  finger  was  upon  the  projjcr  spot 
in  the  first  instance,  there  will  immediately  be  a  recurrence  of 
the  hemorrhage,  and  the  seat  of  the  pressure  is  instantly  changed 
accord  ingl3\ 

A  cold  enema  sometimes  puts  a  sudden  stop  to  it ;  and  another 
excellent  expedient  is  the  application  of  pounded  ice  to  the 
perineum,  or  the  perineum  and  hypogastrium.  Care,  however, 
must  be  taken,  in  the  use  of  the  latter  agent,  that  it  be  not 
continued  too  long,  lest  it  produce  chilliness,  followed  b}^  violent 
reaction.  Benefit  may  also  be  expected,  in  some  cases,  from 
injecting  the  urethra  with  cold  water,  or  some  astringent  lotion, 
such  as  a  solution  of  subacetate  of  lead,  alum,  gallic  acid,  or 
creiisote.  The  fiuid  should  1)0  thrown  up  as  high  as  possible,  in 
a  full  stream,  and  the  operation  should  be  continued  for  a  con- 
siderable length  of  time,  or  until  there  is  reason  to  believe  that 
the  relaxed  or  ruptured  vessels  are  completely  constringed. 

When  the  case  is  obstinate,  and  the  more  ordinary  remedies 
have  failed,  recourse  must  be  had  to  compression  by  means  of  a 
full-sized  elastic  catheter,  introduced  into  the  bladder.  The 
mere  contact  of  the  instrument  frequently  sufiiees  to  arrest  the 
fiow  of  blood  ;  but  should  this  not  answer,  counter-pressure  is 
made  with  the  finger,  a  bandage,  adhesive  strips,  or  when  the 
hemorrhage  is  deep-seated,  with  a  compress  and  roller. 
32 


498  HEMORRHAGE    OF    THE    URETHRA. 

The  best  internal  remedy  in  hemorrhage  of  the  urethra,  is 
gallic  acid,  in  doses  of  from  three  to  five  grains  every  two  or 
three  hours.  Wliere  the  case  is  urgent,  it  may  be  given  more 
liberally,  in  combination  with  opium.  Exhibited  by  itself,  in 
large  doses,  it  is  apt  to  create  nausea  and  vomiting,  and  to  fail 
in  producing  the  desired  eifect.  In  the  spontaneous  variety  of 
this  affection,  gallic  acid  generally  acts  like  a  charm,  completely 
arrci^'ting  the  flow  of  blood  in  a  few  lioui-s.  In  the  traumatic 
form,  although  not  equally  efficacious,  it  rarely  fails  to  be  of 
signal  benefit. 

Another  excellent  remedy  in  this  affection,  is  the  subacetate 
of  lead  in  combination  with  opium ;  three  grains  of  the  former 
with  one  of  the  latter  should  be  given  every  three  hours,  and 
continued  until  the  necessity  for  its  exhibition  ceases.  Alum 
is  another  valuable  agent  in  this  afi'ection.  It  should  be  admin- 
istered in  doses  of  from  thirty  to  sixty  grains  every  two  or  three 
hours.  Employed  in  smaller  quantity,  little  benefit  is  to  be 
looked  for.  In  very  obstinate  cases,  there  are  perhaps  no  arti- 
cles that  hold  out  greater  prospect  of  success  than  spirit  of  tur- 
pentine and  the  tincture  of  the  chloride  of  iron,  in  doses  of  ten 
drops  each,  repeated  every  hour. 


CHAPTER   V. 

FALSE  PASSAGES  OF  THE  URETHRA. 

A  FALSE  passage  is  an  artificial  canal,  comrannicating  with 
the  urethra,  and  generally  produced  by  the  injudicious  use  of 
instruments.  All  portions  of  the  canal  are  subject  to  it,  but  it 
is  most  frequent  in  the  membranous  and  prostatic,  o^Ying  to  the 
inequality  of  their  surface,  and  their  fixed  position  beneath  the 
pubic  symphysis.  A  false  passage  sometimes  occurs  at  the  sinus 
of  the  bulb  from  the  jwint  of  a  catheter  being  arrested  in  it ; 
and  for  the  same  reason  it  occasionall}'^  commences  in  one  of  the 
numerous  follicles  of  the  lining  membrane.  The  accident,  how- 
ever, is  generally  produced  in  consequence  of  the  existence  of  a 
stricture,  in  attempting  to  overcome  which  the  instrument 
leaves  the  natural  channel,  in  front  of  the  obstruction,  and 
makes  a  new  one.  In  cases  of  chronic  enlargement  of  the  pros- 
tate, the  substance  of  this  gland  is  occasionally  perforated,  to 
afi:brd  an  exit  to  the  urine. 

False  passages  are  much  more  easily  made  than  is  generally 
believed,  and  it  is  only  surprising,  when  we  reflect  upon  the 
want  of  anatomical  knowledge  and  dexterity  in  the  use  of 
instruments,  that  they  are  so  seldom  met  with.  When  the 
mucous  membrane  is  softened,  or  chronically  inflamed,  as  it  fre- 
quently is  in  firm,  semicartilaginous  strictures,  it  often  yields 
under  the  slightest  pressure,  and  hence  it  is  not  unlikely  that 
the  accident  occasionally  occurs  when  it  is  not  in  the  least  sus- 
pected. 

The  artificial  route  is  commonly  situated  at  the  inferior  surface 
of  the  canal,  chiefly  because  when  an  instrument  is  attempted 
to  be  introduced  into  the  bladder,  its  point  is  almost  always 
pressed  in  this  direction,  which  also  presents  the  greatest 
number  of  natural  obstacles  to  its  easy  passage.  Sometimes  the 
perforation  occurs  at  the  sides  of  the  urethra  and  occasionally 
also,  but  rarely,  at  its  superior  surface. 

The   leno-th  of  the  artificial  route,  wliicli  is  usually  single. 


500 


FALSE    PASSAGES    OF    THE    UEETHRA, 


varies  from  a  few  lines  to  several  inches.  In  a  specimen  in  my 
private  collection,  from  which  fig.  154  is  taken,  it  Avas  three 
inches  and  a  half,  and  lined  by  a  false  membrane.  Generally 
speaking,  however,  these  false  routes  are  comparatively  short, 
not  exceeding,  perhaps,  ten,  fifteen,  or  twenty  lines. 

Fio;.  154. 


Stricture  of  the  Urethra,  with  False  Passage  ;   Enlargement  of  Ihe  Prostate  Gland,  and 
Hypertrophy  of  the  Bladder. 


False  passages  occur  under  different  varieties  of  form,  of  "which 
the  following  are  the  principal:  1.  The  most  simple,  and  gene- 
rally also  the  least  dangerous  form,  is  where  it  presents  itself  as 
a  cul-de-sac,  or  blind  pouch,  running  parallel  with  the  urethra, 
from  which  it  is  often  separated  merely  by  the  mucous  membrane : 
it  varies  in  length  from  a  few  lines  to  several  inches,  and  may 
occur  in  any  portion  of  the  canal,  although  it  is  most  frequent  at 
its  posterior  part.  2.  In  a  second  variety,  the  false  route,  after 
having  extended  a  certain  distance,  communicates  again  with 
the  urethra,  which  is  thus  perforated  at  two  distinct  points. 
The  abnormal  channel,  in  time,  becomes  lined  by  an  adventitious 
membrane,  and  often  performs  the  functions  of  the  original  one. 
3.  The  passage  communicates  with  the  bladder.  This  variety, 
which  is  by  no  means  infrequent,  is  usually  the  result  of  an 
attempt  to  force  a  stricture  at  the  subpubic  curvature;  in  which 
the  point  of  the  instrument  passes  out  of  the  natural  channel 
into  the  connective  tissue  betAveen  the  rectum  and  the  bladder, 
and  thence  on  into  the  latter  organ.  In  some  instances,  the 
catheter  perforates  the  substance  of  the  prostate,  runs  round  its 
side,  or  proceeds  along  its  upper  surface.  Whatever  course  the 
instrument  may  take  to  reach  the  bladder,  the  occurrence  is 
always  one  of  great  danger,  from  its  liability  to  be  folloAved  by 


FALSE    PASSAGES    OF    THE    URETHRA.  501 

infiltration  of  urine,  and  the  wliole  train  of  evils  which  such  an 
accident  is  capable  of  inducing.  4.  In  a  fourth  variety,  the 
passage  communicates  with  the  rectum.  That  such  an  occur- 
rence should  occasionally  happen,  in  the  hands  of  an  ignorant 
or  unskilful  practitioner,  it  is  not  difficult  to  imagine  when  we 
reflect  upon  the  little  force  it  requires  to  lacerate  the  urethra, 
the  yielding  nature  of  the  connective  tissue  between  the  bowel 
and  the  bladder,  and  the  close  proximity  of  these  two  reservoirs 
to  each  other.  Much  as  the  accident  is  to  be  deprecated,  it  is  a 
remarkable  fact  that  it  is  rarely  followed  by  anything  serious ; 
the  track  neither  admits  urine  nor  fecal  matter,  and,  in  fact, 
usually  closes  in  a  few  hours,  5.  Authors  mention  a  tifth  case, 
in  Avhich  the  abnormal  route  opens  both  into  the  rectum  and  the 
bladder.  To  produce  this  result,  it  is  necessarj^  that  the  vulne- 
rating  body  should,  m  its  onward  passage,  pierce  the  bowel 
twice,  entering  it  at  one  point,  and  emerging  at  another  to  reach 
the  latter  viscus.  An  occurrence  like  this,  of  which  a  remark- 
able example  is  related  by  Deschamps,  might  be  followed  l)y 
severe  inflammation,  and  possibly,  also,  by  a  recto-vesical  tistule. 
6,  and,  finally,  an  instance  is  upon  record  where  the  false  route 
extended  from  the  urethra  to  the  ischium. 

A  false  passage,  in  its  recent  state,  is  merely  a  laceration  of 
the  mucous  membrane  and  the  neighboring  tissues,  which  either 
heals  within  a  short  time  after  it  has  been  radde,  or  it  continues 
open,  and  becomes  lined  by  an  adventitious  membrane,  diftering 
in  no  material  respect,  except  in  the  absence  of  mucous  follicles, 
from  the  natural  structure.  In  time,  the  new  channel  may 
usurp  the  place  of  the  original,  which,  as  it  has  no  longer  any 
functions  to  perform,  gradually  diminishes  in  size,  and  is  occa- 
sionally, especially  in  protracted  cases,  nearly  obliterated. 

The  immediate  cause  of  this  lesion,  as  was  previously  intimated, 
is  undue  force,  or  misdirected  pressure,  exerted  in  the  act  of 
dilating  a  stricture,  cauterizing  the  urethra,  drawing  oflf  the 
urine,  or  sounding  the  bladder.  An  instrument  of  some  kind 
or  other  is  indispensable  to  its  production ;  and  hence  it  is  almost 
needless  to  add  how  important  it  is  for  the  surgeon  to  be  upon 
his  guard  whenever  he  attempts  any  operation,  however  simple, 
upon  the  canal  under  consideration.  To  avoid  the  formation  of 
a  false  passage,  he  should  not  oidy  be  acquainted  witli  the  ure- 
thra in  its  healthy  and  diseased  states,  but  he  should  have  a  most 


502  FALSE    PASSAGES    OF    THE    UEETHRA. 

tliorougli  knowledge  of  the  nature  and  uses  of  the  various  in- 
struments which  are  designed  to  traverse  it,  whether  for  its  own 
benefit  or  for  the  relief  of  the  prostate  gland  and  the  bladder. 

The  predisposing  causes  of  this  lesion  may  be  arranged  under 
two  heads,  the  natural  and  the  accidental.  A  brief  enumera- 
tion of  these  circumstances  will  not  be  without  its  benefit,  for 
it  will  serve  as  a  beacon  to  warn  us  of  the  danger  of  the  heedless 
and  injudicious  use  of  instruments  in  the  treatment  of  urinary 
atfections. 

The  natural  causes  are  the  lacuna  magna,  the  orifices  of  the 
mucous  follicles,  the  sinus  of  the  bulb,  the  margins  of  the  trian- 
gular ligament,  the  anterior  border  of  the  prostate  gland,  and 
the  siiius  pocularis ;  and,  it  is  worthy  of  remark,  that  these  ob- 
stacles to  the  easy  introduction  of  the  catheter  nearly  all  exist 
along  the  inferior  surface  of  the  canal.  Hence,  to  avoid  them, 
the  instrument  should  be  gently  pressed  against  the  upper  part 
of  the  urethra,  after  its  first  inch  and  a  half  are  traversed,  by 
which  its  beak  will  be  made  to  glide  past  these  obstacles  wnthout 
any  danger  of  being  intercepted  by  them.  Care  should  also  be 
taken  that  the  extremity  of  the  instrument  be  not  too  pointed, 
as  this  will  render  it  more  liable  to  become  entangled  in  the  folds 
of  the  lining  membrane  or  in  the  mouths  of  the  mucous  follicles. 

The  accidental  causes,  predisposing  to  the  formation  of  false 
passages,  are,  first,  an  inflamed,  softened,  or  ulcerated  state  of 
the  mucous  membrane;  secondly,  a  preternatural  development  of 
the  mucous  follicles,  or  the  excretory  ducts  of  Cowper's  glands 
and  the  prostate;  thirdly,  the  existence  of  a  tight,  narrow,  semi- 
cartilaginous  stricture  ;  fourthly,  a  deviation  of  the  urethra  from 
its  natural  direction;  and,  fifthly,  the  nature  and  form  of  the 
instrument  used  in  our  operations. 

It  does  not  require  much  foresight  to  perceive  that  the  mucous 
tissue  of  the  urethra,  when  in  a  state  of  disease,  will  be  much 
more  likely  to  give  way,  under  the  pressure  of  a  bougie  or 
catheter,  than  when  it  is  perfectly  healthy.  The  existence,  there- 
fore, of  ulceration  or  softening  of  the  lining  membrane  of  this 
canal  may  be  justly  regarded  as  a  predisposing  cause  to  the  forma- 
tion of  a  false  passage.  The  same  is  true  of  an  unnaturally  large 
follicle,  and  of  a  firm  stricture.  The  situation  of  a  stricture  also 
exerts  an  important  influence  upon  the  production  of  this  lesion. 
The  deeper  it  is  situated  the  less  manageable  is  it  generally  found 


FALSE    PASSAGES    OF    THE    URETHRA.  503 

to  be,  and  the  more  likelj^,  therefore,  will  l)e  the  instrument  to 
tear  the  urethra.  A  deviation  of  this  canal  from  its  natural 
direction  is  by  no  means  rare;  I  have  seen  several  remarkable 
examples  of  it,  and  have  never  known  one  which  did  not  seriously 
embarrass  me  in  my  eiforts  to  introduce  an  instrument  into  the 
bladder. 

Much  also  depends  upon  the  form  and  character  of  the  instru- 
ment used  in  our  operations.  A  flexible  catheter  or  bougie  is 
less  likely  to  produce  mischief  than  a  metallic  one;  a  blunt, 
than  a  conical  one;  a  curved,  than  a  straight  one.  Finally,  a 
great  deal  depends  upon  the  character  of  the  surgeon ;  whether 
he  is  skilful  or  ignorant,  patient  or  hast}',  gentle  or  rough. 

The  effects  of  a  false  passage  vary  according  to  circumstances. 
When  it  consists  of  a  mere  cul-de-sac,  little  or  no  harm  generally 
results.  The  slight  inflammation  which  succeeds  its  formation 
usuall}^  subsides  in  a  few  days,  and  is  just  sufficient,  in  most 
cases,  to  cause  adhesion  of  the  opposite  sides  of  the  artificial 
channel.  The  reason  wdiy  the  accident  so  frequently  occurs,  even 
far  back  in  the  canal,  without  being  followed  by  extravasation 
of  urine,  is  that  the  fluid  does  not  find  an  easy  entrance,  on 
account  of  the  valve-like  opening  in  the  mucous  membrane,  and 
the  oblique  direction  of  the  passage  from  before  backwards, 
wdiich  is  the  reverse  of  the  natural  stream.  When  the  route 
exists  in  the  vicinity  of  the  bladder,  or  when  it  communicates 
wdth  this  reservoir,  the  danger  may  be  very  great,  for  it  may 
then  give  rise  to  infiltration,  abscess,  and  even  gangrene.  When 
it  extends  into  the  rectum,  or  the  rectum  and  bladder,  a  perma- 
nent fistule  ma}'  follow. 

The  formation  of  false  passages  is  seldom  indicated  by  any 
reliable  symptoms,  and  the  consequence  is  that  it  often  occurs 
without  being  suspected  either  by  the  patient  or  the  surgeon. 
The  most  constant  evidences  are,  hemorrhage,  pain,  and  a  feeling 
of  laceration ;  but,  if  these  be  examined  in  detail,  it  will  be 
found,  as  has  been  just  intimated,  that  they  are  of  no  value 
whatever  as  diagnostics.  More  or  less  bleeding,  for  example, 
may  follow^  any  operation  upon  the  urethra,  however  gently  or 
skilfully  conducted.  This  is  true  of  this  canal  both  in  its  healthy 
and  diseased  states.  Every  surgeon  of  experience  has  seen  cases 
in  which  the  slightest  touch  with  a  bougie  or  catheter  has  been 
followed  by  a  tolerablv  smart  hemorrhage.     No  just  inference 


504  FALSE    PASSAGES    OF    THE    URETHRA. 

can  be  deduced  from  tlie  nature  and  amount  of  the  pain  con- 
sequent upon  such  an  injury,  for  the  greatest  possible  diversity 
prevails,  in  this  repect,  in  different  individuals,  depending  upon 
the  natural  or  morbid  sensibility  of  the  canal,  the  state  of  the 
system,  and  the  extent  of  the  laceration.  It  has  been  said  that, 
in  a  false  passage,  it  is  of  a  stinging,  pricking  character;  but 
this  is  not  always  true,  on  the  one  hand,  and  on  the  other,  it  is 
equally  certain  that  the  same  kind  of  sufl'ering  frequently  attends 
the  dilatation  of  a  stricture.  Finally,  the  tearing  sensation, 
complained  of  by  the  patient,  is  altogether  deceptive;  for  it  is 
often  experienced  -when  no  laceration  has  taken  place.  On  the 
whole,  then,  no  confidence  whatever  can  be  jtlaced  in  any  of  the 
symptoms  furnished  by  the  patient.  The  only  circumstances 
worthy  of  notice,  as  far  as  the  surgeon  is  concerned,  are,  first,  a 
peculiar  grating  sensation  communicated  to  his  hand,  wlnle 
engaged  in  operating  upon  the  urethra ;  secondly,  a  sudden  slip- 
ping of  the  instrument  from  its  position,  or  a  feeling  as  if  some- 
thing had  given  way ;  thirdly,  a  deviation  of  the  instrument 
from  the  normal  direction  of  the  canal ;  and,  fourthly,  the  detec- 
tion, by  the  finger  in  the  rectum,  of  the  point  of  the  instrument 
much  nearer  the  anterior  wall  of  the  gut  than  it  should  be,  if 
it  does  not  actually  lie  in  contact  wnth  it,  from  perforation  of 
the  urethra.  Wlien  these  accidents  occur,  the  surgeon  should 
at  once  desist,  and  finish  his  operation  at  some  future  period. 

The  treatment  of  false  passages  must  be  conducted  upon 
general  principles.  Heniori-hage  must  be  arrested,  pain  allayed, 
and  the  use  of  instruments  be  avoided  for  a  fortnight,  when 
the  opening  will  have  closed.  Rest  in  the  recumbent  posture, 
light  diet,  purgatives,  antinionials,  leeches,  fomentations,  and 
the  Avarm  hip-bath  will,  in  general,  put  a  sj^eedy  stop  to  the  local 
intiammation.  The  false  route,  if  complete,  and  consequent  upon 
the  presence  of  an  impermeable  stricture,  will  become  gradually 
lined  by  an  adventitious  membrane,  and  in  a  short  time  take 
tl)e  place,  and  perform  the  ofiice,  of  the  obliterated  part  of  the 
urethra.  Should  retention  of  urine  occur,  and  resist  the  ordinary 
means  of  avoiding  a  false  i:)assage,  as  described  at  page  476,  relief 
nmst  be  attempted,  either  by  performing  external  urethrotomy, 
without  a  guide,  if  this  be  deemed  advisable  or  practicable,  or 
by  puncturing  the  bladder.  If  the  symptoms  indicate  the  exist- 
ence of  urinary  infiltration,  early  and  free  incisions  must  be  made, 
followed  by  anodyne  fomentations,  and  the  usual  internal  means. 


CHAPTER    VI. 

IXFILTRA.TION  OF  URINE. 

By  the  term  "  infiltration,"  as  applied  to  the  urine,  is  iinder- 
stood  an  escape  of  tliis  fluid  from  the  urethra,  and  its  diffusion 
through  the  surroundiug;  tissues.  The  accident  is  always  a 
most  unfortunate  one,  on  account  of  the  serious  effects  to  wliich 
it  is  sure  to  give  rise.  The  urine,  rendered  acrid  by  disease, 
or  by  its  protracted  retention  in  the  bladder,  no  sooner  conies 
in  contact  with  the  tissues  into  which  it  has  escaped  than  it 
lights  up  violent  inflammatory  action,  which  rarely  ceases  but 
with  their  destruction.  The  fluid  in  fiict,  instead  of  being  an 
unirritating  and  harmless  substance,  as  it  is  when  it  is  confined 
within  its  proper  reservoirs,  now  that  it  has  become  unpent, 
plays  the  character  of  a  virulent  poison,  both  to  the  part  and  to 
the  system.  In  a  few  hours  after  the  infiltration  has  taken 
place,  excessive  action  is  set  up ;  the  pain  is  of  a  sharp,  burning, 
stinging  nature  ;  the  skin,  which  presents  an  erysipelatous  blush, 
is  bot,  dry,  and  exquisitely  tender  to  the  touch  ;  the  swelling  is 
great  and  rapid ;  micturition  soon  becomes  impracticable,  if  it 
was  not  already  so  at  the  beginning ;  and  there  is  high  consti- 
tutional excitement,  with  a  rapid  pulse,  dryness  of  the  surface, 
intense  thirst,  excessive  restlessness,  headache,  and  delirium, 
As  the  case  proceeds,  the  affected  parts  assume  a  black,  livid 
ajipearance,  crepitate  on  pressure,  and  are  deprived  of  tlieir 
vitality;  a  urinous  odor  exhales  from  the  infiltrated  structures, 
and  sometimes  even  from  the  whole  body  ;  and  the  patient  sinks 
into  a  low,  typhoid  condition,  which  is  speedily  followed  by 
hiccough,  twitching  of  the  tendons,  cold  clammy  sweats,  tlie 
Ilippocratic  countenance,  deep  coma,  and  death.  The  period  at 
which  the  latter  event  occurs  varies  from  four  to  six  or  eight 
days,  according  to  the  extent  of  the  infiltration,  the  acridity  of 
the  urine,  the  resulting  inflammation,  and  the  state  of  the  system 
at  the  time  of  the  accident.  In  some  instances,  the  smallest 
quantity  of  urine,  not,  perhaps,  exceeding  a  few  dix^'S,  is  suffi- 


506  IXFILTRATIOX    OF    URIXE. 

cient  to  produce  the  most  violent  symptoms  in  four  or  iive 
hours,  followed  by  mortitication  and  death  in  a  few  days ; 
Avhile  in  others,  the  eftusion  may  be  much  more  extensive  and 
yet  the  effects  be  much  more  mild.  Generally,  however,  the 
inflammation  is  of  the  most  severe  character,  and  is  followed  by 
the  worst  consequences. 

The  cause  under  which  infiltration  of  urine  usually  takes  place 
is  a  laceration  of  the  urethra,  either  in  conseG[uence  of  external 
violence,  severe  straining  during  micturition,  as  in  stricture,  the 
passage  of  a  urinary  calculus,  or  the  maladroit  use  of  instruments, 
as  the  catheter  or  bougie.  Wlicn  the  canal  is  ruptured  far  back 
by  a  fall  astride  a  chair,  a  blow,  or  a  kick,  infiltration  of  urine 
is  almost  inevitable.  The  accident  is  sometimes  produced  by 
violent  straining  in  attempts  to  void  the  urine,  on  account 
of  the  obstacle  afforded  by  a  tight,  callous  stricture.  In  this 
affection,  the  portion  of  the  urethra  behind  the  obstruction  is 
often  remarkalily  dilated,  softened,  and  attenuated,  if  not  ulcer- 
ated, and  therefore  liable  to  give  way  under  any  unusual  effort 
at  micturition  ;  the  more  so,  because  the  muscular  fibres  of  the 
bladder  are  generally  at  the  same  time  very  considerably  liyper- 
trophied.  When  the  rupture  follows  upon  such  a  cause,  the 
urine  is  sent  abroad  into  the  connective  tissue  with  great  force, 
as  if  it  had  been  discharged  from  a  syringe,  and  gives  rise  to  the 
most  disastrous  consequences. 

If  the  rupture  takes  place  in  the  commencement  of  the  mem- 
branous portion  of  the  urethra,  behind  the  triangular  ligament, 
the  case  may  remain  obscure  for  several  hours  or  even  days ; 
there  is  little  or  no  prominence  in  the  perineum  from  swelling, 
the  scrotum  is  uninvolved,  and  the  patient  may  not  have  been 
conscious  of  a  sense  of  yielding,  as  he  is  when  the  bladder  gives 
way.  The  urine  is  deep-seated,  and  ma\'  burroAv  extensively 
before  it  declares  itself  externally.  The  most  reliable  symptoms 
of  the  mischief  that  is  going  on,  are,  pain  and  throbbing  deej) 
in  the  perineum  ;  difficulty,  or  utter  impossibility  of  voiding 
tlie  urine,  with,  perhaps,  a  frequent  desire  to  do  so ;  a  sense  of 
fulness  in  the  anus  and  rectum  ;  tenderness  in  the  hypogastrium  ; 
and  extraordinary  constitutional  disturbance.  By  and  by,  the 
urine  makes  an  effort  to  approach  the  surface,  its  progress  being 
preceded  and  accompiinied  by  heat,  pain,  redness,  and  swelling^ 
and  by  a  rapidly  increasing  typhoid  state  of  the  system.      In 


INFILTRATION    OF    URINE.  507 

some  instances,  the  first  evidence  of  sncli  an  attempt,  on  the  part 
of  the  fluid,  is  the  apiiearance  of  a  certain  amount  of  tumefaction 
and  discoloration,  at  first  red,  and  then  purple,  of  the  gland  of 
the  penis ;  showing  that  the  urine  has  obtained  admission  into 
the  spongy  structure  of  this  organ,  and  that  it  is  slowly  but 
surely  extending  its  ravages. 

If  the  rupture  occurs  in  that  portion  of  the  urethra  which  lies 
in  front  of  the  triangular  ligament,  between  it  and  the  bulb,  the 
urine  escapes  into  the  connective  tissue  of  the  perineum,  and 
proceeds  forwards  and  upwards  underneath  the  dartos  into  the 
scrotum,  which  it  often  pervades  through  its  entire  extent.  In 
its  progress,  it  may  travel  along  the  subcutaneous  tissue  of  the 
penis  and  the  groins,  over  to  the  pubes,  and  sometimes  even  as 
high  up  as  the  umbilicus,  or  even  the  chest.  The  passage  of  the 
fluid  is  commonly  indicated  by  a  reddish,  erysipelatous  blush, 
which,  on  the  approach  of  mortification,  is  generally  replaced 
by  a  dark,  livid,  or  black  appearance  of  the  skin.  The  swelling 
of  the  perineum,  scrotum,  and  penis,  in  fact  of  all  the  parts  here 
mentioned,  is  sometimes  excessive.  The  reason  why  the  urine 
does  not,  in  this  variety  of  rupture,  extend  backwards  towards 
the  neck  of  the  bladder,  around  the  anus,  or  downwards  along 
the  thighs,  is  the  manner  in  which  the  triangular  ligament  and 
superficial  perineal  fascia  are  attached  to  each  other  and  to  the 
edges  of  the  hranches  of  the  pubic  and  ischiatic  hones.  There  are, 
however,  notwithstanding  this  arrangement,  cases  in  which  it 
breaks  through  these  barriers,,  and  spreads  backwards  upon  the 
nates  and  the  ischiorectal  fossffi,and  downwards  along  the  inner 
surface  of  the  thighs,  perhaps  to  a  distance  of  many  inches.  In 
the  worst  forms  of  this  affection,  not  only  the  scrotum,  but  the 
skin  of  the  penis,  the  groins,  and  the  upper  parts  of  the  thighs 
fall  into  gangrene,  and  the  testicles,  thus  completely  denuded, 
are  suspended  merely  by  the  spermatic  cords  and  vessels. 

Urinary  infiltration  of  the  scrotum  is  liable  to  he  confounded 
with  ecchymosis  of  this  organ,  the  more  so,  because  both  alfec- 
tions  are  frequently  produced  by  the  same  accident,  namely,  a 
tall  or  blow  upon  the  perineum.  A  careful  examination  of  the 
part,  however,  and  an  attentive  consideration  of  the  history  of 
the  case,  will  generally  enable  us  to  distinguish  the  two  afiec- 
tions.  In  ecchymosis,  the  swelling  and  discoloration  come  on 
within  a  few  minutes,  or,  at  furthest,  a  few  hours,  after  the 


508  IXFILTRATION    OF    URINE. 

occurrence  of  the  injury,  and  are  caused  by  an  extravasation  of 
blood  from  a  rupture  of  some  of  the  scrotal  vessels.  The  patient 
is  in  great  pain,  and  cannot  void  his  urine,  although  he  is  com- 
pelled to  make  frequent  eflforts  to  do  so ;  the  parts  are  more  or 
less  distended  by  the  effused  fluid,  and  the  skin  is  of  a  dark, 
livid,  or  purple  color.  The  pain  in  ecchymosis  is  usually  milder 
than  in  urinary  infiltration,  the  constitutional  excitement  is  also 
less,  and  there  is  an  absence  of  the  peculiar  erysipelatous  blush 
which  generally  precedes  and  accompanies  the  march  of  extrava- 
sated  urine. 

The  symptoms  of  infiltration  of  urine  are  occasionally  most 
painfully  simulated  by  a  form  of  erysipelas  of  the  scrotum  and 
penis,  which  was  originally  described  by  Mr.  Liston  under  the 
name  of  "  inflammatory  oedema,"  and  is  liable  to  attack  persons 
of  intemperate  habits  and  dilapidated  constitutions.  The  aftec- 
tion,  which  progresses  rapidly,  is  attended  with  enormous 
swelling  of  the  scrotum  and  penis,  of  a  glossy-reddish  aspect, 
very  painful,  and  pitting  deeply  on  pressure.  The  patient  is  pale, 
feeble,  and  dejected  ;  the  [)ulse  is  small,  quick,  and  tremulous ; 
the  respiration  is  frequent  and  embarrassed;  the  strength  soon 
gives  way  ;  micturition  is  diflUcult ;  and  if  relief  is  not  promptly 
aftbrded,  gangrene  ensues.  The  diagnosis  is  based  upon  the 
histor}^  of  the  case,  the  absence  of  previous  urinary  trouble,  the 
rapidity  and  great  extent  of  the  swelling,  and  the  facility  with 
which  the  catheter  is  passed. 

The  prognosis  of  infiltration  is  seldom  flattering,  although 
apparently  the  most  desperate  cases  occasionally  recover.  Much 
will  necessarily  depend  upon  the  nature  and  extend  of  the  lesion 
which  gives  rise  to  it,  the  state  of  the  system  at  the  time  of  the 
injury  and  the  promptness  and  judgment  with  which  the  accident 
is  managed  in  its  earlier  stages.  If  the  urethra  is  extensively 
lacerated,  so  that  little  or  no  urine  can  pass  ofiF  in  that  direction ; 
if  the  patient  is  old  or  dilapidated  at  the  time  the  mischief  is 
inflicted,  and  if  the  extravasated  fluid  has  become  extensivel}'' 
diffused,  little  hope  is  to  be  entertained  of  a  favorable  issue. 
Death  will  be  likely  to  happen  in  spite  of  all  that  can  be  done. 
The  case  is  generally  regarded  as  desperate  when  the  urine  is 
extravasated  into  the  spongy  body  of  the  penis ;  an  occurrence 
which  is  commonly  preceded  by  severe  pain  and  tenderness  of 
the  part,  and  a  livid  discoloration  of  the  head  of  the  organ. 


INFILTRATIOX    OF    URIXE.  500 

Balarina  mentions  a  case  of  recovery  where  there  was  slouiih- 
ing  not  only  of  the  integuments  of  the  penis  and  scrotum,  hut 
of  the  connective  tissue  of  the  loins  and  ahdomen,  as  high  uji  as 
the  umhilicus,  and  of  the  thigh  as  far  down  as  the  knee.  The 
patient  had  a  good  constitution,  and  proper  counter  openings 
were  made. 

The  treatment  of  infiltration  of  urine  must  be  prompt  and 
energetic,  otherwise  serious  mischief,  if  not  loss  of  life,  will  be 
the  result.  The  first,  and  in  fact  almost  the  only  thing,  to  be 
done,  in  the  early  stage  of  the  affection,  is  to  make  large  and 
dependent  incisions,  to  afford  vent  to  the  pent-up  and  irritating- 
fluids,  provide  for  the  subsequent  escape  of  the  urine  from  the 
bladder,  and  also  afibrd  an  outlet  for  pus  and  sloughs.  The 
parts  must  be  cut  freely,  not  sparingly,  at  different  points,  and 
to  as  great  a  depth  as  is  consistent  with  the  safety  of  the  large 
vessels  of  the  perineum.  The  incisions  should,  of  course,  be 
made  vertically,  not  obliquely,  much  less  transversely.  It  is 
surprising  to  what  an  extent  the  affected  parts  may  frequently 
be  divided.  Incisions  that  would  shock  an  inexperienced  or 
timid  practitioner  are  borne  with  perfect  impunity,  and  often 
heal  with  little  deformity.  In  violent  cases,  mere  scarification 
is  worse  than  useless.  The  door  must  be  widely  opened,  and 
the  intruder  must  be  forced  out  with  a  bold  hand. 

As  soon  as  the  distended  parts  have  been  freely  and 
thoroughly  divided,  and  the  system  has  rallied,  a  gum-elastic 
catheter  should  be  introduced  into  the  bladder,  and  be  allowed 
to  remain  there  during  the  cure.  The  urine  is  thus  enabled  to 
pass  off  as  fast  as  it  reaches  the  bladder,  and  is  thereby  pre- 
vented from  doing  further  mischief.  The  gum-clastic  catlieter 
is  preferable,  in  these  cases,  to  a  silver  one,  on  account  of  its 
greater  softness  and  pliancy,  which  enable  it  to  aceonnnodate 
itself  more  readily  to  the  urethra,  altered  and  distorted  as  it 
frequently  is  by  the  accompanying  tumefaction.  The  intro- 
duction of  an  instrument  of  any  kind  is  often  attended  with 
immense  difficulty  and  is  sometimes  utterly  impracticable. 

The  best  local  applications,  after  tbe  parts  have  been  properly 
incised,  are  warm  fomentations  of  acetate  of  lead  and  opium, 
hops  or  poppy  heads.  They  should  be  frequently  renewed,  and 
their  heat  and  moisture  should  be  maintained  by  oiled  silk. 
When  the  sloughing  process  has  fiiirly  begun,  the  fomentations 


510  INFILTRATIOX    OF    URIXE. 

may  be  advantageously  superseded  by  emollient  poultices,  with 
the  addition  of  yeast,  port  wine,  nitric  acid,  or  chlorinate  of  soda, 
l)roperly  temjiered  with  water.  AVlien  the  eschars  are  detached, 
the  sore  is  to  be  managed  upon  general  principles.  Throughout 
the  treatment,  the  scrotum  and  penis  are  to  be  supported  with 
a  suspensory  bandage.  Should  the  parts  remain  fistulous,  an 
operation  may  be  required  for  their  relief,  but  not  until  they 
have  become  thoroughly  cicatrized  in  the  neighborhood  of  the 
abnormal  apertures.  It  is  sur[)rising,  even  when  there  has  been 
the  most  extensive  sloughing,  how  rapidly,  in  some  instances, 
nature  succeeds  in  repairing  the  injur}-.  The  testicles,  as  was 
before  stated,  are  sometimes  entirely  denuded,  or,  [lerhaps, 
merely  suspended  by  the  spermatic  cords,  and  yet,  contrary  to 
what  might  be  supposed  to  happen  in  such  cases,  the  breach  is 
frequently  closed  in  a  very  brief  space  with  comparatively  little 
deformitj'. 


CHAPTER  VII. 


URINARY  ABSCESS. 

Abscesses,  to  which  the  term  urinary  is  usually  applied,  are 
liable  to  form  in  the  connective  tissue  around  the  urethra,  iij^. 
155,  leading,  if  improperly  managed  to 
fistule  and  other  mischief.  The  expression 
is  a  generic  one,  and  is  emploj^ed  to  desig- 
nate any  collection  of  pus,  the  exciting 
cause  of  which  is  an  escape  of  urine  from 
the  urinary  passages  into  a  part  which  is 
unaccustomed  to  its  presence,  and  which, 
therefore,  never  fails  to  resent  the  intru- 
sion. Thus,  a  urinary  abscess  sometimes 
forms  deep  in  the  pelvis,  in  the  perineum, 
or  above  the  pubes,  after  puncture  of  the 
bladder,  the  operation  of  lithotomy,  or 
injury  of  the  bladder  from  a  ball,  saln-e,  or 
splinter  of  bone.  As  applied  to  tlie  ure- 
thra, the  term  '•  urinary"  is  not  sufficiently 
definite ;  for  it  denotes  merely  one  circum- 
stance in  the  history  of  tliis  lesion,  namely, 
the  nature  of  the  exciting  cause.  The 
nomenclature  might  be  improved  hy  tlie 
substitution  of  the  word  "  urethral,"  or, 

still  better,  by  the  term  "  periurethral,"  inasmuch  as  it  would 
serve  to  point  out  at  once,  not  only  the  character  of  the  affec- 
tion, but  likeAvise  its  situation. 

The  ordinary  site  of  urinary  abscess  is  the  iicrineum,  l)etAvecn 
the  bull)  of  the  uretlira  and  the  anus.  A  very  common  situa- 
tion is  the  upper  part  of  the  perineum,  just  behind  the  junction 
of  the  cavernous  bodies  of  the  penis,  and,  consequently,  at  the 
inferior  portion  of  the  scrotum.  The  next  most  frequent  point 
is  the  scrotum  itself,  and,  lastly,  the  under  surface  of  the  penis. 
Instances  are  observed,  although  they  are  rare,  in  which  the 
abscess  forms  at  the  side  of  the  anus,  at  the  nates,  near  the  tip 


Urinary  Abscess. 


r)12  URIXARY    ABSCESS. 

of  tlio  coccyx,  and  at  the  upper  and  inner  part  of  the  tliigh. 
It  seldom  happens  that  more  than  one  such  swelling  occurs  at 
a  time.     There  niay,  however,  be  as  man}-  as  two  or  even  three. 

The  exciting  causes  of  the  lesion  are  various.  The  most 
common,  perhaps,  is  the  existence  of  a  tight  organic  stricture 
of  the  urethra,  attended  with  attenuation  and  dilatation  of  the 
canal  immediately  posterior  to  it.  A  sort  of  pouch  is  thus 
formed,  in  which  the  urine  habituallj'  lodges,  fretting  and  teas- 
ing the  mucous  membrane  until  it  produces  perforative  ulcera- 
tion. However  minute  the  opening  may  be,  a  small  quantity  of 
fluid  is  sure  to  insinuate  itself  into  the  subjacent  connective 
substance,  and  to  give  rise  to  inflammation.  Or,  instead  of  this, 
the  weakened  and  dilated  part  behind  the  seat  of  the  obstruc- 
tion may  yield  at  one  or  more  points  during  a  violent  eftbrt  at 
micturition,  while  the" patient  is,  perhaps,  straining  with  all  his 
might  to  relieve  the  bladder  of  its  accumulated  load.  A  little 
crack,  or  fissure,  not  larger,  it  may  be,  than  a  pin's  head,  may 
thus  become  a  source  of  immense  mischief  and  trouble.  Or  a 
rough,  angular  calculus  may  lodge  in  the  urethra,  and  tear  the 
mucous  membrane,  either  as  it  is  forced  along  by  the  pressure 
of  the  urine,  or  during  an  attempt  at  manual  extrusion.  Or  a 
false  route  may  bo  made  with  a  Ijougie,  sound,  or  catheter ;  or 
the  urethra  may  be  perforated  by  a  sharp,  narrow-pointed  instru- 
ment, or  it  may  be  lacerated  by  a  fall  astride  a  chair,  the  bough 
of  a  tree,  or  an  iron  railino-.  It  is  worth  v  of  remark,  that  when 
tlie  urethra  is  opened,  to  any  considerable  extent,  by  external 
violence,  however  inflicted,  infiltration  will  be  much  more  likely 
to  result  than  abscess.  It  is  only,  in  fact,  when  the  aperture  is 
exceedingl}^  small,  or  where,  if  the  reverse  is  the  case,  it  is 
speedily  glazed  with  lymph,  that  the  one  will  be  apt  to  be  pre- 
vented and  the  other  to  form. 

An  abscess  of  this  description  is  sometimes  produced  in  an- 
other way.  Pus,  for  example,  is  formed  in  the  periurethral  con- 
nective tissue,  and  gradually  extends  inwards  until  it  ultimately 
causes  ulcerative  absorption  of  the  lining  membrane,  followed  by 
an  escape  of  the  matter  into  the  canal,  and  the  ingress  of  a  small 
quantity  of  urine  into  the  cavity  of  the  abscess.  Thus  an  abscess 
that  is  originallj^  simple  maj^  be  converted  into  a  urinary  abscess. 
A  boil,  a  carbuncle,  or  an  erj'sipelas,  commencing  in  the  skin 
and  subjacent  connective  texture,  may  lead  to  the  same  eftect. 


URINARY    ABSCESS.  513 

Abscesses  exterior  to  the  urethra  are  liable  to  form  under  a 
variety  of  circumstances,  of  which  the  most  important  are 
gonorrhoea!  inflammation,  stricture,  and  external  injury. 

There  are  cases  in  which  this  variety  of  abscess  forms  witliout 
any  obvious  causes,  or  without  apparently  any  previous  or  co- 
existent lesion  of  the  urethra.  This  aftection  is  very  tardy  in 
its  progress,  and  seems  to  be  occasionally  connected  with  a 
scrofulous  state  of  the  constitution.  In  this  respect  it  bears  a 
striking  resemblance  to  those  abscesses  which  are  sometimes 
developed  around  the  anus,  in  the  subjects  of  phthisis. 

Urethral  abscesses  are  generally  small  and  cireumscril)ed,  not 
diffused,  as  in  urinary  infiltration,  properly  so  called  ;  for  in  the 
one  case  the  irritating  fluid,  under  the  influence  of  which  the}' 
are  developed,  is  bounded,  or  walled  in,  by  a  deposit  of  plastic 
material,  while  in  the  other  it  is  sent  abroad  into  the  connective 
tissue,  and  often  spreads  over  an  jilmost  incredible  extent  of  sur- 
face: depriving  lymph,  skin,  and  other  structures  rapidly  of 
their  vitality.  In  this  respect,  a  urinary  abscess  may  be  said  to 
hold  the  same  relation  to  urinary  infiltration  that  a  common 
boil  does  to  a  carbuncle.  In  the  one,  the  swelling  is  small,  and 
circumscribed ;  in  the  other,  it  is  dift'used,  the  attendant  de[iosit 
being  cacoplastic,  and,  consequently,  incapable  of  setting  limits 
to  the  extravasated  fluid. 

The  first  evidence  of  an  abscess  of  this  kind  is  usually  a  small, 
deep-seated  lump,  tender  on  pressure,  hard,  distinctly  circum- 
scribed, and  more  or  less  movable.  This  gradually  increases  in 
bulk,  and  manifests  a  disposition  to  approach  the  surfiice,  al- 
though, in  general,  six  or  eight  days  will  elapse  before  it  attains 
this  point.  The  integument,  previously  free  from  discoloration, 
now  assumes  an  erysipelatous  blush,  and  often  pits  slightly  on 
pressure;  the  pain  and  tension  steadily  augment;  the  structures 
around  feel  stiff  and  uncomfortable;  tiirobbing  takes  place;  the 
urine  is  passed  with  unusual  diflficulty,  from  mechanical  com- 
pression of  the  urethra;  and  the  patient  is  seized  with  shivering, 
alternating  with  flushes  of  heat.  In  this  stage  of  the  aflection, 
the  skin  is  hot  and  dry,  the  tongue  is  brown,  the  pulse  is  falter- 
ing, the  thirst  is  intense,  and  there  is  excessive  restlessness  with 
a  tendency  to  delirium.  In  the  worst  variety  of  the  lesion,  the 
scrotum  is  oedematous,  the  perineum  bulges  out  in  the  ^orm  of  a 
large  tumor,  the  parts  around  the  anus  are  swollen  and  tender, 
83 


ol-i  URINARY    ABSCESS. 

defecation  is  painful,  micturition  is  difficulty  if  not  impracticable, 
and  the  patient  is  unable  to  walk  about,  or  even  to  sit  or  stand. 
The  contents  of  a  urinary  abscess  are  generally  thin, dark-colored, 
acrid,  and  more  or  less  fetid.  The  pus,  Avhicli  contains  compara- 
tively few  corpuscles,  is  usually  intermixed  with  lymph,  urine, 
and  the  d(^bris  of  the  attectcd  parts. 

There  is  a  form  of  this  atiection  in  which  the  symptoms  are 
of  a  milder  character,  and  which  is  almost  entitled  to  the  appel- 
lation of  chronic.  I  have  seen  it  more  commonly  in  persons  of 
a  debilitated  frame,  with  a  tendency  to  tubercular  disease  of  the 
lungs  or  other  parts  of  the  bod}-.  The  swelling,  in  such  eases, 
is  remarkably  tardy,  and  is  seldom  larger  than  a  pigeon's  egg  or 
a  common  marble.  It  is  rarely  attended,  at  least  for  the  first 
week  or  ten  days,  by  any  pain,  and  there  is  but  little  discolora- 
tion of  the  skin.  If  left  to  itself,  from  twelve  to  eighteen  days 
will  elapse  before  it  will  break  and  discharge  its  thick  and  ill- 
elaborated  contents. 

The  diagnosis  of  this  disease  is  not  always  so  easy  as  might, 
at  first  sight,  be  supposed.  Its  character  may  be  suspected  when 
a  tumor,  small,  hard,  circumscribed,  and  almost  indolent,  forms 
deeply  in  the  perineum,  or  along  the  middle  of  the  scrotum,  in 
connection  with  stricture  of  the  urethra,  chronic  gonorrhoea,  or 
disease  of  the  neck  of  the  bladder ;  when  its  progress  is  unusually 
tardy,  when  it  gradually  approaches  the  surface,  and  when  the 
skin,  [treviously  to  giving  way,  is  of  a  red,  erysipelatous  aspect. 
In  the  acute  variety  of  the  lesion,  in  which  the  symptoms  are  of 
a  bolder  character,  the  local  afiection  is  generally  accompanied, 
especially  after  the  fii*st  five  or  six  days,  by  excessive  constitu- 
tional disturbance,  a  feeble,  faltering  pulse,  rigors,  restlessness, 
and  typhomania.  In  the  traumatic  form,  a  strict  inquiry  into 
the  history  of  the  case,  particularly  as  to  the  manner  of  its  occur- 
rence, with  a  careful  examination  of  the  part,  will  usually  enable 
us  to  arrive  at  a  correct  conclusion.  After  all,  however,  the 
matter  is  not  one  of  much  moment,  in  a  practical  sense,  for  in 
all  doubtful  cases,  attended  with  local  swelling  and  difiiculty  of 
micturition,  the  treatment  is  the  same. 

Whatever  may  be  the  size,  situation,  progress,  or  real  character 
of  an  abscess  of  the  urethra,  it  is  always  necessarily  folloAved  by 
a  fistule,  "through  which  the  urine  is  afterwards  discharged,  either 
partly  or  wholl}-,  much  to  the  discomfort  and  inconvenience  of 


URIXARY    ABSCESS.  515 

the  patient.  The  disease,  therefore,  although  seldom  dangerous 
to  life,  is  always  to  be  dreaded  on  account  of  this  circumstance, 
Avhich  is  so  much  the  more  unfortunate,  because  it  does  not  al- 
ways admit  of  relief  b}'  treatment. 

The  treatment  of  urinary  abscess  is  sufficiently  simple.  The 
antiphlogistic  regimen,  rest,  recumbencj-,  leeching,  and  fomen- 
tation, will  limit  the  morbid  action ;  and  an  early  external  inci- 
sion will  prevent  the  diffusion  of  the  matter  and  the  urine.  If 
stricture  be  present,  it  is  removed  in  the  ordinary  manner. 
AVhen  the  sac  has  been  emptied,  and  the  accompanying  inflam- 
mation has,  in  a  great  measure,  disappeared,  a  catheter  should 
be  retained  in  the  l)ladder,  to  prevent  the  escape  of  its  contents 
by  the  abnormal  orifices,  the  edges  of  which  are  to  be  touched, 
from  time  to  time,  with  nitrate  of  silver,  to  promote  cicatrization. 
If  the  parts  around  the  aperture  remain  hard  and  callous,  they 
should  be  pencilled,  once  a  day,  with  tincture  of  iodine,  or  well 
rubbed  with  camphorated  mercurial  ointment,  to  stimulate  the 
absorl)ents,  and  hasten  the  removal  of  effused  fluids. 


CHArTEK   VIII. 
FISTULE  OF   THE  URETHRA. 

A  FISTULE  is  ail  accidental  track,  narrow,  straight,  or  tortnoiis, 
lined  by  an  adventitious  membrane,  and  conimiinicating,  on  the 
one  hand,  with  the  urethra,  and,  on  the  other,  with  the  cutaneous 
surface.  Its  most  common  site  is  that  portion  of  the  canal  which 
corresponds  with  the  perineum,  and  the  scrotum ;  the  disease 
sometimes  occurs  farther  back,  and  occasionally  it  exists  near 
the  anterior  orifice.  A  rare  form  of  fistule  sometimes  supervenes 
upon  the  operation  of  lithotomy,  the  abnormal  channel  extend- 
ing from  the  urethra  to  the  rectum. 

The  abnormal  tracks  vary  much  in  extent.  Those  which 
occur  in  the  spongy  portion  of  the  urethra  are  always  very  short, 
while  those  which  implicate  the  membranous  and  bulbous  parts 
are  sometimes  remarkably  long  and  sinuous.  Cases  have  been 
witnessed  in  which  they  have  passed  down  the  thigh,  backwards 
towards  the  anus,  outwards  towards  the  nates,  inwards  towards 
the  pelvis,  or  upwards  into  the  groin  and  the  hypogastric 
region. 

Every  fistule  of  this  kind  has  two  openings,  of  which  the 
internal  one  is  usually  single,  however  numerous  may  be  the 
branches  of  the  abnormal  track,  or  however  riddled  the  cutaneous 
surface.  In  some  cases,  two,  three,  and  even  four  orifices  exist 
in  the  urethra;  but  this  is  very  rare,  and  alwa^'S  constitutes  a 
serious  impediment  to  a  permanent  cure.  The  internal  opening 
is  generally  of  an  irregular  shape,  and  varies  in  size  between  the 
smallest  pin's  head  and  the  end  of  the  little  finger. 

The  number  of  external  openings,  fig.  156,  varies  in  diflterent 
cases.  Generally  speaking,  there  is  but  one,  or,  at  most,  two 
or  three.  I  have  never  seen  more  than  five.  Ledran'  met  with 
an  instance  of  thirty ;  and  Civiale^  refere  to  one  of  fifty-two. 
When  tlie  number  is  considerable,  the  afltected  surface  presents 

'  Traite  des  Operations  de  Chirurgie,  p.  368. 

2  Traite  sur  les  Maladies  des  Organes  Geuito-Urinaires,  Premier  partie,  p.  393. 


FISTULE    OF    THE    URETHRA. 


517 


a  riddled,  sieve-like  aspect.  N"o  regularity  prevails  in  regard  to 
the  form  and  size  of  the  external  apertures.  They  may  be 
circular,  triangular,  or  ovoidal,  or  they  may  have  the  appearance 
of  a  slit,  rent,  or  fissure;   and  in  their  dimensions  they  may  be 


Fior.  156. 


Fistvile  of  tlie  Urethra. 


so  small,  on  the  one  Land,  as  to  be  hardly  visible,  and  so  large, 
on  the  other,  as  to  admit  tlie  end  of  a  probe,  a  grooved  director, 
or  a  goose-quill.  Tlie  situation  of  the  external  orifice  is  usually 
indicated  by  the  presence  of  a  red,  fleshy  papilla,  which  projects 
sliglitly  beyond  the  level  of  the  surrounding  surface,  and  is  con- 
stantlj^  bathed  with  purulent  matter,  or  pus  and  urine.  Occa- 
sionally the  ojDening  has  a  sort  of  valve-like  arrangement. 

The  abnormal  track  may  be  straight  or  sinuous,  single  or  mul- 
tiple. If  a  probe  be  introduced  into  the  external  orifice,  it  may 
pass  on  towards  the  urethra  in  a  direct  line,  and  this  generally 
happens  when  the  disease  occupies  the  spongy  portion  of  the 
urethra;  on  the  other  hand,  the  passage  is  frequently  remarkably 
tortuous,  especially  if  it  be  long,  or  situated  in  the  perineum  or 
scrotum.  In  most  cases,  there  is  at  first  only  one  track,  but  as 
this  is  liable  to  obstruction,  fresh  infiannnation  is  excited,  a  new 
abscess  forms,  and  in  this  way  another  channel  is  added  to  the 
previous  one.  Thus,  the  original  track  possesses  a  sort  of  multi- 
plying power,  which  is  often  employed  to  the  great  detriment 
both  of  the  part  and  of  the  system. 

The  abnormal  channel  is  originally  nothing  but  a  sinus,  or 
tubular  nicer,  which  soon  becomes  covered  by  granulations,  and 
ultimately  by  an  adventitious  membrane,  which  in  cases  of  long 


518  FISTULE    OF    THE    URETHRA. 

standing,  generally  acquires  a  dense,  fibrous  character.  The 
fluid  furnished  by  the  new  passage  is  generally  thin  and  gleety, 
and  mingled  with  the  natural  secretions  or  excretions  of  the 
urethra.  When  the  lining  membrane  is  inflamed  or  irritated, 
it  is  sometimes  entirel}-  suspended,  or  of  a  bloody,  sanious,  puru- 
lent, or  a  mucopurulent  character.  The  quantity  of  urine  flow- 
ing along  it  varies  from  a  few  drops  to  several  ounces  in  the 
twenty-four  hours ;  and  cases  are  not  wanting,  especially  when 
the  fistule  is  a  consequence  of  impermeable  stricture,  in  which 
all  the  water  is  discharged  through  it.  The  abnormal  passage 
occasionally  contains  one  or  more  calculous  concretions,  from  the 
volume  of  a  mustard  seed  to  that  of  a  cherry  or  hazelnut.  They 
are  developed  in  the  passage,  or  they  are  conveyed  into  it  acci- 
dentally from  the  bladder  or  the  prostate  gland.  The  parts  in 
the  immediate  vicinity  of  the  tistule  are  variously  aftected. 
Sometimes  they  are  almost  natural,  or  the  changes  which  they 
have  undergone  are  so  slight  that  it  is  difiicult  to  detect  them; 
most  generally,  however,  they  are  considerably  swollen,  very 
much  indurated,  chafed,  excoriated,  and  exquisitely  sensitive. 
If  cut,  they  ofter  more  or  less  resistance  to  the  knife,  and  emit 
a  peculiar  grating  noise.  When  the  irritation  has  been  very 
protracted,  and  the  patient's  health  long  deranged,  they  some- 
times become  the  seat  of  carcinomatous  degeneration.  It  is  not 
often  that  the  periosteum  and  the  bones  sufter  in  this  disease, 
since  their  deep  situation  is  generally  an  effectual  protection 
against  the  contact  of  the  urine. 

The  immediate  cause  of  this  affection  is  the  destruction  of 
the  mucou-s  membrane,  produced  by  ulceration,  abscess,  gangrene, 
or  laceration,  and  followed  by  an  escape  of  urine  into  the  con- 
nective tissue.  Here,  acting  as  a  powerful  irritant,  the  fluid 
speedily  excites  inflammation,  which  soon  terminates  in  suppu- 
ration, or,  it  may  be,  in  the  death  of  the  aflected  parts.  When 
the  matter  is  evacuated,  or  the  slough  detached,  the  urine,  being 
no  longer  pent  up,  issues  at  the  accidental  opening,  which  now 
constitutes,  in  the  legitimate  sense  of  the  term,  a  fistule. 

The  efficient  causes  of  urethral  fistule  are  various.  The  most 
frequent,  undoubtedly,  is  stricture,  attended  with  dilatation  of 
the  canal  behind  the  seat  of  the  obstruction ;  but  it  may  also 
result  from  ill-managed  attempts  to  pass  instruments,  or  from 
the  protracted  sojourn  of  catheters  and  bougies,  from  gonorrhoea. 


FISTULE    OF    THE    UEETHRA.  519 

retention  of  urine,  external  violence,  shot  wounds,  and  the  ope- 
ration of  lithotomy.  I  have  several  times  seen  the  urethra 
become  fistulous  in  consequence  of  chancre,  situated  either  witliin 
the  canal,  and  extending  outwards,  or  commencing  on  the  surface 
of  the  penis,  and  proceeding  inwardly.  Occasionally,  the  disease 
originates  in  obstruction  of  the  canal  by  a  urinary  calculus.  The 
mucous  membrane  behind  the  obstacle  is  gradually  dilated  and 
attenuated,  and  finally  takes  on  ulceration,  which,  advancing  to 
the  deeper  structures,  leads  to  an  escape  of  urine,  and  the  forma- 
tion of  an  abscess.  The  opening  left  by  the  evacuation  of  the 
matter  remains  fistulous,  and  affords  vent  to  the  urine.  The 
same  train  of  phenomena  takes  place  in  stricture.  The  mucous 
membrane  posterior  to  the  obstruction,  being  constantly  fretted 
and  irritated  by  the  presence  of  the  urine,  ultimately  gives  way, 
and  the  disease  in  question  is  the  speedy  consequence. 

A  person  afl'ected  with  urethral  fistule  is  to  be  regarded  as  an 
object  of  the  deepest  sympathy  and  commiseration.  Although 
he  may  be  able  to  retain  his  urine  for  a  considerable  interval, 
or,  perhaps,  even  the  usual  period,  yet  whenever  he  attempts  to 
void  it,  a  certain  quantity  always  escapes  at  the  abnormal  chan- 
nel, wetting  his  clothes,  and  irritating  the  skin  of  the  perineum, 
the  scrotum,  and  the  thighs.  When  the  opening  is  situated  far 
back,  there  may  be  an  incessant  dribbling,  and,  in  such  a  case, 
no  care  can  secure  his  comfort,  or  protect  him  from  the  offensive 
smell  which  exhales  from  him  wherever  he  goes.  The  parts  in 
the  immediate  vicinity  of  the  fistule  are  constantly  sore,  swollen, 
excoriated,  and  suljject  to  new  attacks  of  inflammation,  which 
are  often  followed  by  new  abscesses  and  new  tracks.  In  the  more 
severe  forms  of  the  complaint,  the  patient  finds  it  difficult,  if 
not  impossible,  to  move  about,  or  take  his  accustomed  exercise : 
the  bladder  becomes  irritable,  and  intolerant  of  its  contents; 
the  calls  to  micturition  increase  in  frequency;  the  urine  is 
loaded  with  mucus,  and  exhales  a  disagreeable,  ammoniacal 
odor;  the  general  health  declines;  the  appetite  fails ;  the  body 
wastes  ;  and  the  poor  sufferer,  abandoned  to  despair  and  wretch- 
edness, hails  death  as  a  welcome  messenger. 

The  diagnosis  of  this  disease  is  usually  easy.  An  opening  exists 
in  some  po'i-tion  or  other  of  the  urethra,  giving  vent  to  urine  either 
in  drops,  in  jets,  or  in  a  continuous  stream,  synchronous  witli 
the  act  of  micturition.     The  quantity  of  fluid  evacuated  by  the 


o20  FISTULE    OF    THE    URETHRA. 

natural  route  usually  varies  with  the  character  and  degree  of  the 
obstruction  upon  which  the  tistule  depends.  In  some  instances, 
nearly  the  whole  passes  off  by  the  accidental  passage  ;  in  others, 
only  a  few  drops  or  teaspoonsful.  When  the  track  is  situated 
in  the  membranous  or  prostatic  portion  of  the  canal,  the  urine 
may  dribble  away  constantly  ;  but  this  is  rare.  A  probe,  of 
small  size,  introduced  into  the  external  orifice,  readily  enters 
the  urethra,  provided  the  abnormal  passage  is  not  very  narrow, 
oblique,  angvilar,  or  sinuous.  When  this  is  the  case,  it  may  be 
difficult,  if  not  impossible,- to  effect  the  object,  however  adroitly 
or  perseveringly  the  operation  may  be  conducted. 

In  regard  to  their  prognosis,  it  may  be  observed  that  ure- 
thral fistules  are,  in  general,  a  source  of  inconvenience  rather 
than  of  danger.  When  the  disease  is  of  an  aggravated  charac- 
ter, and  is  complicated  with  an  intractable  stricture,  life  may 
gradually  be  destroyed  by  constitutional  irritation,  or  by  local 
suffering  from  disease  of  the  bladder,  the  prostate  gland,  or  the 
kidneys.  In  simple  fistule  no  such  result  is  to  be  apprehended. 
The  case,  if  well  managed,  is  productive  of  little  trouble,  and  is 
readily  relieved  by  treatment.  AVhen  the  affection  is  accom- 
panied by  great  loss  of  substance,  or  when  it  involves  the  pos- 
terior and  more  deeply-seated  portions  of  the  canal,  it  may  be 
incurable,  and  render  the  patient  miserable  for  life.  A  tistule 
of  the  urethra  has  sometimes  been  followed  by  impotence,  not 
from  a  want  of  erection  or  ability  to  copulate,  but  on  account 
of  the  escape  of  the  greater  part  of  the  spermatic  fluid  by  the 
accidental  route. 

The  treatment,  although  obvious,  is  not  always  easy.  The 
first  thing  to  be  done  is  to  seek  for,  and,  if  possible,  to  remove, 
the  exciting  cause.  In  most  cases  this  will  be  found  to  be  a 
stricture,  probably  of  long  standing,  upon  the  division  of  wdiich, 
and  the  restoration  of  the  urethra  to  its  natural  calibre,  the 
abnormal  track  ordinarily  closes  of  its  own  accord.  To  prevent 
the  contact  of  the  urine  with  the  internal  opening  of  the  fistule, 
the  patient  should  be  taught  to  empty  his  bladder  at  stated 
intervals  with  the  soft,  bulbous  catheter.  Conducted  upon  these 
principles  this  mode  of  treatment  rarely  fails  in  the  more  mild 
and  uncomplicated  form  of  the  malady.  It  sometimes,  however, 
happens,  after  all  obstruction  in  the  urethra  has  been  removed, 
that  the  fistule  manifests  no  disposition  to  heal,  but  remains 


FI3TULE    OF    THE    URETHRA.  521 

pervious  to  the  urine.  Several  causes  may  give  rise  to  tins 
occurrence.  In  the  first  place,  it  may  be  owing  to  the  presence 
of  a  calcareous  concretion,  which,  as  was  previously  stated, 
sometimes  forms  in  a  passage  of  this  kind,  and  prevents  it  from 
closing.  The  proper  remedy,  of  course,  in  such  a  case,  is  to 
remove  the  foreign  body,  for  as  long  as  it  remains  no  progress 
towards  a  cure  can  be  expected.  The  extraction  may  be  effected 
either  with  the  forceps  alone,  as  when  the  passage  is  very 
spacious ;  or  with  the  forceps  and  knife  when  it  is  narrow,  or  small 
and  sinuous.  Secondly,  the  indisposition  to  unite  may  depend 
upon  the  presence  of  an  abnormal  pouch,  or  upon  an  unusually 
large  internal  orifice.  In  either  case,  the  proper  remedj-  is  a 
free  incision,  so  as  to  enable  the  parts  to  heal  from  the  bottom. 
Thirdly,  the  occurrence  may  be  owing  to  the  peculiar  nature 
of  the  lining  mendjrane  of  the  accidental  track,  which  may  be 
of  a  firm,  almost  semicartilaginous  consistence,  and  be  con- 
stantly bathed,  on  its  free  surface,  with  a  thin,  glairy  mucus, 
thus  preventing  the  opposite  sides  from  adhering.  When  this 
is  the  case,  the  object  should  be  to  destroy  the  secreting  surface, 
and  to  promote  the  granulating  process,  by  means  of  stinndants 
or  escharotics.  One  of  the  best  remedies  for  accomplishing  this 
end  is  the  nitrate  of  silver,  which  may  be  used  either  in  sub- 
stance, as  when  the  fistule  is  very  shallow,  or  in  the  form  of  a 
tolerably  strong  solution,  carefully  introduced  with  a  small 
ivory  syringe  or  a  conmion  probe.  Forty  grains  of  the  salt  to 
the  ounce  of  water  is  the  proportion  which  I  usually  employ, 
and  I  seldom  repeat  the  application  oftener  than  once  every 
forty-eight  hours.  Sometimes  I  have  used  Avith  advantage  a 
piece  of  sulphate  of  copper,  cut  to  a  delicate  point,  and  retained 
for  ten  or  twelve  seconds  in  the  abnormal  passage.  In  obstinate 
cases,  recourse  may  be  had  to  the  occasional  introduction  of  a 
heated  wire,  or  to  a  probe  di]iped  in  nitric  acid,  a  concentrated 
solution  of  lunar  caustic,  or  the  acid  nitrate  of  mercury.^  Too 
much  caution,  however,  cannot  be  observed  in  the  use  of  these 
and  similar  remedies,  which  are  w^ell  calculated,  if  applied  too 
freely,  to  cause  severe  inflammation  and  even  sloughing.  The 
object,  in  all  cases,  should  simply  be  to  destroy  the  lining 
membrane,  without  involving  any  of  the  surrounding  tissues. 
Anv  tendency  to  premature  closure  of  the  external  orifice  13 


522  FISTULE    OF    THE    URETHRA. 

prevented  by  touching  its  margins,  every  few  clays,  with  caustic 
potassa,  or  some  other  escharotic  substance. 

When  the  fistule  is  ol)stinate  and  protracted ;  wlien  its  in- 
ternal orifice  is  uncommonly  large,  or  when  there  are  several 
openings  of  this  kind ;  or,  finally,  when  it  depends  upon  an 
old  stricture  so  firm,  narrow,  and  extensive,  that  it  cannot  be 
destroyed  in  the  ordinary  manner,  the  only  course  left  is  to  lay 
the  parts  open  hy  an  external  incision  ;  a  procedure  which  often 
remarkably  expedites  the  cure  of  both  affections. 

When  the  fistule  involves  the  spongy  portion  of  the  urethra, 
and  has  been  caused  by  chancre,  or  external  injury,  attended 
with  loss  of  substance,  it  may  be  necessary  to  have  recourse  to 
suture,  as  the  more  ordinary  means  not  infrequently  fail,  in  con- 
serpience  of  the  difliculty  with  which  the  accidental  opening 
cicatrizes  in  this  situation.  The  suture  usually  employed  is  the 
twisted,  made  with  very  short,  slender  needles,  placed  not  more 
than  a  line  and  a  half  apart.  A  medium-sized  catheter  having 
been  previously  introduced  into  the  bladder,  the  edges  of  the 
opening  are  carefully  pared,  as  in  hare-lip,  and  then  nicely  ap- 
j)roximated,  the  ends  of  the  ligatures  being  passed  from  one 
needle  to  the  other,  the  points  of  which  are  next  cut  off  with 
the  forceps.  Instead  of  this  suture,  some  surgeons  recommend 
the  interrupted,  which,  however,  does  not  possess  any  advantages. 
Dieft'enbach  suggested  the  plan  of  running  the  suture  round  the 
fistulous  orifice,  after  the  fashion  of  a  purse-string,  the  epidermis, 
loosened  by  the  application  of  tincture  of  cantharides  to  the 
margin  of  the  opening  and  the  surrounding  skin,  having  pre- 
viously been  scraped  away.  When  the  thread  is  tightened,  it 
draws  the  skin  into  puckers,  and  approximates  the  edges  of  the 
aperture  so  completely  as  to  enable  them  occasionally  to  unite 
by  the  first  intention.  Several  cases  in  which  this  treatment 
has  been  successfully  employed  have  been  published  by  Dieffen- 
bach  and  other  surgeons. 

The  principal  objection  to  the  employment  of  the  suture,  in 
uny  form,  for  the  relief  of  this  aftection,  is  its  liability  to  tear 
itself  out  before  the  completion  of  the  adhesive  process,  in  conse- 
quence of  the  morbid  erections  which  are  so  apt  to  take  place 
after  the  operation.  It  is  this  occurrence  which  so  frequently 
mars  the  result  of  our  efforts,  and  renders  it  necessary  to  repeat 
tliem.     To  o-iiard  ao;ainst  these  erections,  which  often  become 


FISTULE    OF    THE    URETHRA. 


523 


troublesome  witliin  the  first  few  hours  after  the  operation,  re- 
course should  he  had  to  anodyne  enemata,  or  suppositories  of 
opium  and  camphor,  and  to  the  application  of  pounded  ice  to 
the  perineum  and  hypogastrium. 

Excision  has  sometimes  been  practised  with  advantage.  When 
the  parts  in  which  the  stricture  is  situated  are  unusually  callous 
and  circumscribed,  an  elliptical  portion,  embracing  the  external 
orifice,  is  cut  out,  and  the  raw  surfaces  are  approximated  by 
suture  over  a  silver  catheter,  previously  introduced  into  the 
bladder. 

When  the  fistule  is  attended  with  considerable  loss  of  sub- 
stance, urethroplasty  may  become  necessary.  This  term  is  em- 
ployed to  designate  a  process  which  has  for  its  object  the  restora- 
tion, by  the  transplantation  of  a  piece  of  healthy  integument,  of 
a  part  of  the  urethra  that  has  been  lost,  either  partially  or  wholly, 
by  accident  or  disease.  The  operation,  which  requires  no  little 
skill  for  its  successful  issue,  is  chiefly  applicable  to  fistules  open- 
ing into  the  spongy  portion  of  the  canal.  Different  modes  of 
urethroplasty  have  been  devised,  each  of  which  possesses,  per- 
haps, certain  advantages  in  particular  cases;    none  of  them. 


Fia;.  157. 


Fig.  158. 


Dieflfenbach's  Method  of  Urethroplasty. 


NOlatou's  Method  of  UrethropUsly, 


however,  are  very  certain  in  their  results,  and  hence  it  is  a  good 
rule  never  to  resort  to  them  as  long  as  there  is  any  prospect  of 
affording  relief  by  other  means. 


524 


FISTULE    OF    THE    URETHRA. 


Ficr.  lo9. 


One  of  the  most  simple  of  these  processes  is  that  of  Dieften- 
bach,  represented  in  iig.  157,  Avhich  consists  in  paring  the  raw 
edges  of  the  opening  over  a  catheter,  previously  introduced  into 
the  bladder,  so  as  to  form  a  crescentic  cleft,  the  long  diameter 
of  which  corresponds  with  that  of  the  penis.  A  longitudinal 
incision  is  then  made  on  each  side  of  the  cleft,  when  the  inter- 
vening integuments  are  raised  in  two  bridge-like  flaps,  and 
united  closel}^  at  the  middle  line  by  numerous  points  of  the 
interrupted  suture,  over  a. piece  of  India  rubber,  or  strip  of  thin 
lead,  Avith  the  view  of  preventing  contact  of  the  urine.  In 
Xelaton's  operation,  which  is  one  of  the  most  siiccessful,  after 
refreshing  the  edges  of  the  fistule,  the  surrounding  integuments 
are  dissected  up  subcataneously  iu  the  manner  represented  in 
fig.  158,  through  which  the  edges  of  the  abnormal  opening  are 
easily  approximated  by  a  few  points  of  suture. 

Alliot,  anxious  to  avoid  the  inconveniences  which  so  fre- 
quently result  from  the  contact  of  the  urine  with  the  raw  edges, 
circumscribes  and  dissects  a  small  square  flap  on  one  side  of  the 
accidental  channel,  and  removing  from  the 
other  side  a  portion  of  skin  equal  to  the  flap, 
covers  the  opening  and  the  loss  of  substance 
with  the  latter,  which  is  securely  fastened  by 
tlie  twisted  suture.  In  this  way  the  line  of 
union  is  carried  out  of  the  way  of  the  urine 
as  it  passes  through  the  urethra.  This  in- 
genious process  seems  to  have  l)een  completely 
successful  in  the  hands  of  its  inventor. 

The  Indian  method,  as  it  is  called,  fig.  159, 

is  performed  b}'  closing  the  gap  by  borrowing 

integuments  from  the  neighboring   parts,  as 

the  scrotum,  penis,  or  the  groin.     The  callous 

edges  of  the  opening  are  previousl}'  very  freely 

pared  so  as  to  produce  a  large  new  surface, 

when  a  portion  of  sound  skin  is  dissected  up, 

except  at  one  point,  and  inserted   into   the 

wound,  to  which  it  is  loosely  fitted  and  secured 

by  suture.     This  method  is  the  only  one  that  is  at  all  likely  to 

eventuate  in  success,  when  a  large  portion  of  the  urethra  has 

been  destroyed. 

In  this,  as  well  as  in  all  operations  which  have  for  their  object 


Cretliroplasty  by 
Scrotal  Flap. 


FISTULE    OF    THE    URETHRA.  525 

the  closure  of  a  fistule,  or  the  restoration  of  a  portion  of  tlie  ure- 
thra, I  conceive  it  to  be  a  matter  of  paramount  importance  to 
divert  the  urine  into  some  other  channel  until  adhesion  is  accom- 
plished. The  operation  has  been  sanctioned  by  high  authority, 
and  has  been  employed  successfully  in  several  instances.  In  a 
case  treated  by  Ricord,  with  whom  the  suggestion  originated, 
the  opening  was  situated  anterior  to  the  scrotum,  in  the  spongy 
portion  of  the  urethra  ;  in  Avhich,  from  the  great  thinness  and 
mobility  of  the  tissues,  it  is  almost  impossible  to  secure  thorough 
closure.  He  made  an  incision  into  the  membranous  urethra, 
and  kept  it  open  for  the  passage  of  the  whole  of  the  urine  until 
the  accidental  track  was  comyjletely  united,  when  it  was  per- 
mitted to  close.  The  patient  had  been  previously  subjected  to 
various  methods  without  the  slightest  benefit. 


CHAPTER    IX. 

PROLAPSE  OF  THE  MUCOUS  MEMBRANE  OF  THE  URETHRA. 

The  mucous  membraue  of  tlie  urethra,  like  that  of  the  Wad- 
(ler,  with  which  it  is  continuous,  is  liable  to  become  inverted 
and  prolapsed  at  the  external  orifice  of  that  canal.  The  aft'ec- 
tion  is  extremely  rare,  and  is,  for  obvious  reasons,  confined  to 
the  female  sex.  It  is  chiefly  met  with  in  children,  in  conse- 
quence of  repeated  and  long-continued  efforts  at  straining,  and 
is  characterized  by  the  existence  of  a  tumor  which  is  generally 
of  a  cylindrical,  rounded,  or  globular  shape,  soft  in  consistence, 
of  a  reddish  or  purple  hue,  and  entirely  free  from  pain  and 
soreness,  except  when  it  has  been  chafed,  irritated,  or  inflamed. 
Its  precise  situation  is  towards  the  superior  part  of  the  vulva, 
between  tlie  pudendal  lips,  where  it  may  be  seen  projecting  from 
tlie  orifice  of  the  urethra,  which  is  itself  usually  considerably 
dilated,  for  the  more  ready  extension  of  the  investing  membrane 
of  which  it  is  composed.  The  centre  of  the  tumor  always  con- 
tains a  distinct  opening,  corresponding  to  the  external  meatus 
of  the  canal,  and  large  enough  to  admit  the  passage  of  a  medium- 
sized  catheter.  It  varies  in  size  from  a  pea  to  a  pullet's  egg,  and 
a>  the  protrusion  advances,  the  investing  membrane  becomes 
hypertropliied,  preternaturally  red,  and  beset  with  enlarged  and 
varicose  veins,  and  the  urethra  is  proportionately  dilated  for  the 
reception  and  passage  of  the  affected  structures. 

It  is,  in  general,  sufficienth'  easy  to  distinguish  between  this 
affection  and  inversion  and  prolapse  of  the  bladder,  described 
elsewhere.  The  most  important  diagnostic  signs  are  that  in  the 
former,  the  tumor  is  usually  much  smaller  than  in  the  latter, 
that  it  is  more  cylindrical  or  slender  in  its  figure,  that  it  is  not 
liable  to  be  attended  with  incontinence  of  urine,  and  that  it 
does  not  receive  any  distinct  impulse  when  the  patient  coughs, 
laughs,  or  sneezes.  When  the  tumor  is  formed  by  the  inverted 
bladder,  we  are  generally  able  to  detect  the  orifices  of  the 
ureters,  while  in  the  disease  under  consideration  there  is,  of 


PROLAPSE    OF    MUCOUS    MEMBRANE    OF    URETHRA.       527 

coiu-se,  no  such  appearance.  It  is  readily  distinguished  from 
polyp,  by  its  non-pedunculated  appearance,  and  by  the  fact  that 
it  forms  a  distinct  rin^  around  the  oriiice  of  the  uretlira. 

In  the  treatment  of  this  disease,  special  attention  is  to  be 
paid  to  the  manner  of  voiding  the  urine.  Instead  of  observin<»- 
the  usual  posture,  the  patient  should  lie  on  her  side  or  back, 
lest  the  tumor  l)e  forced  doAvn  before  the  stream,  and  thus,  bv 
the  frequent  repetition  of  the  act,  be  permitted  gradually  to 
augment  in  volume.  When  the  protrusion  has  already  made 
considerable  progress  a  cure  will  hardly  be  possible  without  the 
constant  use  of  the  catheter  and  the  aid  of  astringent  lotions 
and  injections.  The  general  health,  if  impaired,  should  be 
aiKended  by  tonics  and  other  moans  calculated  to  invigorate 
the  system,  and  impart  strength  to  the  affected  structure-^. 
Recumbency,  long  continued  and  steadily  persisted  in,  will,  in 
nearly  all  instances,  be  an  indisjiensable  adjuvant.  When  the 
disease  is  obstinate,  or  has  resisted  the  more  ordinary  remedies, 
excision,  ligation,  or  the  application  of  strong  nitric  acid,  may 
become  necessary. 


CHAPTER   X, 


TUMORS  OF  THE  URETHRA. 


Xkoplasms  of  the  urethra  are  of  infrequent  occurrence.  As 
a  primary  atfection,  the  only  ones  met  with  are  the  fibrous, 
either  as  polyjioid  or  papilhary  growths,  and  the  vaseuhir.  Car- 
cinoma is  always  the  result  of  extension  of  the  disease  from  the 
bladder,  prostate,  or  gland  of  the  penis.  The  fibrous  and  vascu- 
lar growths  are  more  common  in  the  female  than  in  the  male, 
and  nearly  always  originate  in  the  posterior  wall  of  the  canal. 

a.  Polypoid  fibroma,  or  polyp,  usually  springs  from  the  navi- 
cular fossa  of  the  male;  sometimes,  and  particularly  in  elderly 
subjects,  it  is  situated  farther  back,  as  in  the  case  recorded  by 

^-ir  Henry  Thompson,'  and  represented 
in  fig.  160,  in  which  a  growth  of  this 
nature,  about  nine  lines  long  by  three 
in  Avidth,  was  found  at  the  junction  of 
the  membranous  and  prostatic  portions 
of  the  canal.  In  women,  they  are  also 
generally  situated  near  the  external 
meatus,  so  that  during  their  progress, 
they  not  unfrequently  project  beyond 
the  pudenda.  In  rare  instances,  they 
occupy  the  posterior  part  of  the  urethra, 
and  may  then  pass  into  the  bladder,  or, 
as  in  a  case  recorded  by  Dr.  "W.  H.  Wil- 
liams,^  of  Louisiana,  separate  the  vulva. 
The  growth,  which  was,  larger  than  a 
hen's  egg,  and  attached  by  a  double  ped- 
icle near  the  inner  meatus,  had  distended 
the  urethra,  so  that  it  readily  admitted 
of  the  passage  of  three  fingers. 
In  the  male,  the  number  of  these  tumors  varies  from  one  to 
three  or  four;  frequentl}-,  they  are  solitary.     In  their  volume 


Polypoid  Fibroma  of  Urethra. 


'   Op    cit.,  p.  87. 

2  Buffalo  Medical  aud  Surgical  Journal,  April,  1809. 


TUMORS    OF    THE    URETHRA.  529 

they  range  between  the  smallest  pin's  head,  and  an  ordinary 
bean.  Their  shape  is  irregular;  pyriform,  conical,  or  spheroidal. 
The}''  are  of  a  reddish  complexion,  compressible  and  elastic  in 
their  consistence,  while  their  surface  is  sometimes  perfectlj'  uni- 
form and  smooth,  and,  at  other  times,  granulated,  or  lobulated. 
When  minutel}'  examined,  the}^  are  found  to  consist  of  a  succu- 
lent, delicate  tibrous  tissue,  which  is  rarely  well  jirovided  with 
bloodvessels,  and  to  be  invested  by  a  prolongation  of  the  liniiiir 
membrane  of  the  urethra. 

Polypoid  fibroma  is  generall}^  free  from  pain,  in  which  respect 
it  diiiers,  and  that  remarkably,  from  the  vascular  growths  de- 
scribed below.  They  rarely  advance  beyond  the  size  above 
mentioned,  are  usually  unattended  by  mucous  or  purulent  dis- 
charge, and  seldom  materially  obstruct  micturition.  In  the 
female,  hoAvever,  it  may  not  only  attain  the  volume  of  an  egg, 
and  give  rise  to  constant  incontinence  of  urine  and  great  impair- 
ment of  the  general  health,  as  in  the  case  of  Dr.  Williams,  but 
it  may  even  acquire  the  bulk  of  a  large  fist.  In  an  instance  of 
this  nature,  occurring  in  a  woman  of  forty-one,  who  suffered 
from  dysuria  and  constipation,  a  soft  fibroid,  weighing  three 
pounds,  and  projecting  from  the  genitals  through  the  meatus, 
Avhich  was  an  inch  long,  was  removed  by  Dr.  Honing.' 

Fibrous  polyps  are  tardy  and  insidious  in  their  development, 
and  when  deeply  seated,  they  may  exist  for  many  years,  without 
the  possibility  of  detection.  As  they  are  generally  very  soft, 
they  are  liable  to  be  pressed  to  one  side  by  the  passage  of  a  solid 
instrument,  so  that  the  exploratory  bulbous  bougie  affords  the 
only  means  of  establishing  the  diagnosis  Avhen  they  are  of  small 
bulk  and  deeply  seated. 

The  removal  of  these  excrescences  is  best  affected  by  excision 
with  the  scissors,  the  wound  being  touched  immediately  after- 
wards with  chromic  acid,  nitrate  of  silver,  or  sulphate  of  copper, 
with  the  view  to  prevent  repullulation.  In  the  event  of  hemor- 
rliage,  the  raw  surface  may  be  seared  with  the  hot  iron  ;  or  a  bit 
of  lint,  wrung  out  of  Monsel's  solution,  may  be  firmly  pressed 
upon  it,  until  the  blood  entangled  in  its  meshes  has  coagulated. 
When  such  a  tumoi-  is  deeply  seated,  it  may  be  torn  away  l>y  the 

'  Biennial  Retrospect  for  1869-70,  p.  b73. 

34 


580  TUMORS    OF    THE     URETHRA. 

urethral  forceps,  or  by  the  ingenious  procedure  of  Dr.  Eberm.inn.' 
This  consists  in  introducing  an  endoscopic  tube,  the  end  of  which 
is  closed,  and  entangling  tlie  growth  in  its  large  oval  eye,  when 
a  second  tube,  the  extremity  of  which  is  open  and  sharp,  is 
passed  into  the  former,  and  the  polyp  cut  away.  On  withdraw- 
ing the  latter  tube,  the  wound  is  cauterized  with  nitrate  of  silver. 
When  the  growth  is  located  far  back,  and  of  large  bulk,  an  inci- 
sion may  have  to  be  made  down  upon  it,  through  the  spongy 
body  of  the  urethra. 

p.  Papillarj",  or  villous  tibroma,  or  papilloma,  occasionally 
occurs  in  the  male  urethra  as  a  result  of  inflammation  of  its 
mucous  membrane.  In  one  instance,  that  of  a  young  man,  of 
twenty-four,  who  was  under  my  charge  some  years  ago,  the  tumor, 
which  was  situated  just  behind  the  urinary  meatus,  and  of  the 
size  of  a  hemp-seed,  was  evidently  of  a  gonorrhceal  origin.^ 
Their  number  seldom  exceeds  half-a-dozen,  although  they  may 
stud  the  mucous  membrane  of  the  urethra  from,  one  extremity 
to  the  other.  In  a  very  remarkable  case  recorded  by  Roger,^ 
the  vegetations,  which  formed  dendritic,  club-shaped  villosities, 
from  the  size  of  a  pin's  head  to  that  of  a  pea,  reached  from  the 
bulb  to  the  meatus,  greatly  distending  the  urethra,  which 
measured  two  inches  and  two-fifths  in  circumference  at  the  level 
of  the  bulb.  The  walls  of  the  canal  were  greatly  thickened  and 
indurated.  The  patient  had  always  suffered  from  dysuria,  which 
amounted  to  retention  for  twenty-four  hours  before  his  death 
from  phthisis,  and  the  enlarged  and  lengthened  penis  was  always 
in  a  state  of  semierection. 

l*apilloma  usually  presents  itself  as  a  congeries  of  long,  fila- 
mentous, dendritic  villi,  forming  a  mass  which  varies  in  size  from 
a  pin's  head  to  that  of  an  egg.  Occasionally,  it  resembles  an 
acuminated  lobular  condyloma,  its  surface  presenting  a  cauli- 
flower appearance,  and  being  attached  by  a  broad  base,  as  in 
fig.  161,  from  Lambl.^  The  growth,  which  was  excised  without 
any  hemorrhage,  from  tlie  urethra  of  a  young  girl  by  Professor 
Seyfert,  was  of  fourteen  years'  duration,  and  had  occasioned  no 

'  St.  Petersburger  Mediciu.  Zeitschrift,  Bd.  viii.,  1865,  p.  353. 

2  In  a  case  under  the  care  of  the  editor,  a  similar  growth  sprung-  from  the 
cicatrice  left  by  the  division  of  a  stricture,  a  quarter  of  an  inch  behind  the 
meatus.  3  Gazette  Hebdom.,  No,  32,  1860,  p.  555. 

*  Prajcr  Yierteljahrschrift,  Bd.  I.,  1856,  p.  21. 


tum'ors  of  the  urethra, 


531 


urgent  symptoms  except  some  difficulty  in  micturition.  It  was 
as  large  as  a  small  egg^  and  each  papilla  was  composed  of  a 
beautiful   network  of   bloodvessels,  held   together  by  delicate 


P;(,)iill(ima  of  Urethra. 

connective  tissue,  and  invested  by  polygonal  tcsselated  epithelial 
cells,  which  is  the  ordinary  histological  construction  of  these 
tumors. 

The  symptoms  and  treatment  of  this  form  of  fibrous  growth 
do  not  difter  from  those  of  polypoid  fibroma. 

y.  Vascular  Tumors. — This  variety  of  morbid  growth  of  the 
urethra  is  generally  denominated  the  "  vascular  tumor,"  "  vascu- 
lar polyp,"  "  vascular  excrcvscence,"  or  "caruncle."  It  is  very 
ditlerent  in  its  structure  from  the  preceding,  and  is  in  great 
measure,  if  not  entirely,  peculiar  to  the  female,  being  usually 
situated  just  within  the  margin  of  the  urinary  meatus,  or  in  the 
anterior  portion  of  the  canal.  In  some  instances,  however,  it 
lies  farther  back,  and  may  then  project  slightly  into  the  l)ladder. 
Cases  also  occur  in  which  it  occupies  the  parts  immediately 
around  the  urinary  meatus.  Occasionally,  although  rarely,  the 
excrescences  are  found  simultaneously  in  all  these  situations. 

The  vascular  polyp  of  the  urethra  is  of  a  bright  fiorid  color, 
exquisitely  sensitive,  and  of  a  conical,  ovoidal,  or  rounded  form. 
In  its  volume  it  varies  from  that  of  a  large  pin's  head  to  that  of 
a  currant,  a  pea,  or  a  cherry,  which  latter  it  rarely  exceeds.  Its 
attachment  is  generally  by  a  tolerably  broad  base,  but  in  many 
cases,  especially  when  it  is  jiyriform,  it  adheres  by  a  narrow 
pedicle.  In  number,  it  varies  from  one  to  ten  or  fifteen, 
although,  in  genel'al,  it  does  not  exceed  three  or  four.  Fre- 
quently, in  fact,  it  is  solitary.     When  several  exist,  they  are 


532  TUMORS    OF    THE    URETHRA. 

either  isolated,  or  grouped  together.  In  its  structure,  this  variety 
of  tumor  is  essentially  vascular,  and  hence  it  frequently  hleeds 
upon  the  slightest  touch.  Minutely  examined,  it  is  found  to  con- 
sist of  a  congeries  of  minute  vessels,  arterial  and  venous,  which 
are  held  together  hy  delicate  mucous  or  connective  tissue,  and 
invested  by  pavement  epithelium.  From  tlie  exquisite  pain  of 
which  it  is  the  seat,  it  is  evident  that  it  must  also  be  well  sup- 
plied with  nerves,  although  it  is  not  easy  to  demonstrate  their 
existence.  Thus  constituted,  it  is  of  a  soft,  spongy  consistence, 
and  of  an  erectile  character,  with  a  smooth  and  florid  surface. 

Considerable  diversity  obtains  in  regard  to  the  appearance  of 
these  tumors,  depending,  probably,  not  so  much  upon  any  pecu- 
liarity in  their  organization,  as  upon  their  age  and  the  degree  of 
irritation  to  whicli  they  are  subjected.  Thus,  instead  of  being 
of  a  bright  red,  scarlet  color,  they  are  sometimes  quite  pale, 
grayish,  spotted,  or  purple.  Their  surface  is  occasionally  fissured, 
obulated,  or  rough  and  granulated,  like  a  raspberry,  or  studded 
with  small  villosities.  Their  sensibility,  although  generally  ex- 
quisite, is  sometimes  very  slight,  or  almost  null. 

The  growth  of  these  excrescences  is  usually  tardy.  After 
they  have  attained  a  certain  volume,  they  frequently  advance 
in  an  imperceptible  manner,  or  romain  stationary  altogether. 
Their  origin  is  commonly  insidious,  and  hence  a  considerable 
period  often  elapses  before  the  patient  is  rendered  aware  of  their 
existence,  or  before  their  true  nature  is  suspected  by  the  practi- 
tioner. Of  their  causes  nothing  whatever  is  known.  They 
seem  to  be  developed  in  the  submucous  connective  tissue,  and, 
as  already  stated,  they  never  attain  a  larger  bulk  than  a  cherry 
or  a  pigeon's  egg,  whatever  may  be  their  age  or  situation.  They 
are  not  confined  to  any  particular  period  of  life,  but  are  most 
common  in  married  females,  after  the  age  of  thirty-five  or  forty. 
They  rarely,  if  ever,  occur  before  tho  time  of  puberty.  I  have 
met  with  them,  in  one  instance,  in  a  girl  of  seventeen,  and,  in 
another,  in  a  married  woman  of  sixty-three. 

The  characteristic  features  of  these  tumors  are,  their  florid 
complexion,  their  exquisite  sensibility,  their  insidious  origin, 
their  slow  development,  and  their  small  size.  The  suftering 
which  attends  them  is  often  so  great  as  to  render  the  patient 
utterly  miserable,  and  unfit  for  the  ordinary  duties  of  life.  It 
is  much  increased  by  walking,  the  erect  posture,  sexual  inter- 


TUMORS  OF  THE  URETHRA.  583 

course,  micturition,  and  even  the  contact  of  the  dress.  The 
slig-htest  touch,  indeed,  is  commonly  intolerahle.  The  y»ain, 
\vl)ich  is  frequently  of  a  sharp,  shooting  character,  extends,  in 
many  cases,  into  the  pelvis,  up  the  back,  and  down  the  thiglis. 
From  the  situation  of  the  morbid  growths,  micturition  is  me- 
chanically obstructed  ;  the  stream  of  urine  is  sometimes  reduced 
to  the  size  of  the  smallest  thread,  and  the  evacuation  of  the  fluid 
is  accompanied  with  a  hot,  scalding  sensation,  severe  pain,  great 
straining,  and,  occasionally,  slight  hemorrhage.  The  bladder  is 
excessively  irritable,  and  there  is  almost  a  constant  inclination  to 
void  its  contents.  Occasionally,  the  symjitoms  closely  simulate 
those  of  stone,  or  carcinoma  of  the  vagina.  In  the  more  aggra- 
vated forms  of  the  affection,  the  general  health  is  apt  to  sutler; 
symptoms  of  dyspepsia  gradually  show  themselves  ;  the  stomach 
is  weak  and  flatulent ;  the  bowels  are  constipated ;  the  urine  is 
high-colored,  scanty,  and  acid ;  the  spirits  are  depressed  ;  the 
imtient  is  unable  to  move  about,  or  take  the  slightest  exercise, 
and  the  system  is  finally  worn  out  by  feverish  excitement, 
melancholy,  and  loss  of  sleep.  Little  discharge  attends  these 
tumors,  except  when  they  are  chafed  or  irritated  by  exercise, 
when  they  are  liable  to  become  inflamed,  and  to  pour  out  a  thin 
mucopurulent  fluid. 

There  is  little  probability  that  vascular  growths  will  be  con- 
founded with  other  morbid  growths  of  the  female  urethra  and 
its  external  orifice.  The  tumors  for  which  they  are  most  liable 
to  be  mistaken  are  the  verrucous,  from  which,  however,  they 
may,  in  general,  be  easily  distinguished  by  their  history,  the 
peculiarity  of  their  situation,  their  florid  appearance,  their  great 
sensibility,  and  the  obscure  nature  of  their  origin.  The  verru- 
cous excrescence  is  placed  exterior  to  the  urethra,  upon  the 
vestibule,  is  insensible,  does  not  bleed  Avhen  touched,  and  is  of 
the  same  color  as  the  surface  from  which  it  grows.  It  is  always 
accompanied,  moreover,  by  a  mucous  discharge,  and  is  generally 
multiple.  The  polvpoid  tumor,  although  occupying  the  same 
situation,  is  easily  distinguished  from  the  vascular  tumor  by  its 
larger  size,  its  want  of  sensibility,  its  paler  color,  and  its  indis- 
position to  bleed  even  when  rudely  touched.  Like  the  vascuhir 
excrescence,  it  may  obstruct  the  flow  of  urine,  but  it  is  never 
attended  with  the  local  and  general  distress  which  characterize 
the  other  o-.owth.     It  need  hardly  be  added  that   no  opinion 


634  TUMORS    OF    THE    URETHRA. 

should  ever  be  given  concerning  any  tumor  in  this  situation 
without  a  thorough  examination,  both  tactile  and  visual. 

A  case  is  mentioned,  under  the  head  of  Inversion  of  the  Blad- 
der, where  a  tumor,  formed  by  a  prolapse  of  the  organ,  came 
very  near  being  mistaken  for  a  vascular  growth.  It  happened 
in  a  child  between  tAvo  and  three  years  of  age;  the  swelling  was 
about  the  size  and  shape  of  a  walnut,  with  a  rough,  granular 
surface,  not  unlike  tliat  of  a  large  strawberry.  The  professional 
attendant  proposed  to  remove  it  with  a  ligature,  which  he  was 
about  to  apply,  when  another  surgeon,  who  was  called  into  con- 
sultation, fortunately  detected  the  true  character  of  the  disease, 
and  thus  saved  the  child's  life. 

Although  these  tumors  are,  in  general,  not  dangerous,  yet 
they  may,  by  the  protracted  irritation  to  which  they  give  rise, 
occasionally  destroy  life,  or  reduce  the  patient  to  the  very  verge 
of  the  grave.  When  extirpated,  or  removed  by  caustic  or  liga- 
ture, they  are  apt  to  return,  and  to  acquire,  in  a  short  time, 
their  original  volume.  Occasionally  they  assume  a  malignant 
tendency,  and  gradually  degenerate  into  ojien  sores,  which 
manifest  no  disposition  to  heal,  and  which  discliarge  a  thin,  foul, 
irritating  ichor. 

The  treatment  of  this  variety  of  tumor  is  strictly  of  a  local 
character.  Constitutional  remedies,  beyond  their  effect  of  im- 
proving the  secretions  and  imparting  tone  to  the  system,  are  of 
no  benefit.  Attempts  have  been  made  from  time  to  time  to 
repress  this  morbid  growth  by  astringent  and  sorbefacient  appli- 
cations, such  as  acetate  of  lead,  Goulard's  extract,  tincture  of 
iodine,  and  nitrate  of  silver;  but  without  success.  Instead, 
therefore,  of  wasting  his  time  in  this  way,  the  surgeon  should 
proceed  at  once  to  the  employment  of  the  only  remedy  known 
to  be  capable  of  affording  permanent  relief,  namely,  excision. 
This  may  be  accomplished  either  with  the  knife  or  the  scissors, 
according  to  the  situation  of  the  tumor.  Seizure  is  effected 
with  a  small  double  hook,  or  a  pair  of  broad-bladed  forceps;  the 
morbid  growth  is  put  gently  on  the  stretch,  or,  if  situated  far 
back,  carefully  drawn  forward,  and  then  pared  or  snipped  off* 
with  one  stroke  of  the  instrument,  close  to  the  mucous  surfiice, 
or,  if  possible,  so  as  to  include  a  portion  of  this.  Where  this 
cannot  be  done,  the  surgeon  waits  till  the  bleeding  has  ceased, 
and  then  tonches  the  cut  surface  with  chromic  acid,  followed  by 


TUMORS    OF    THE    UKETIIRA.  535 

a  strong  solution  of  carbonate  of  soda  to  neutralize  that  airent. 
The  object  of  this  procedure  is  to  destroy  the  deep-seated  portion 
of  the  excrescence,  and,  by  modifying  the  capillary  action  of 
the  part,  to  guard  against  its  reproduction,  which  is  otherwise 
almost  certain  to  take  place. 

When  the  tumor  is  situated  some  distance  within  the  urethra, 
it  may  become  necessary,  as  a  preliminary  measure,  to  dilate  the 
canal  in  the  same  manner  as  when  the  surgeon  wishes  to  extract 
a  urinary  calculus.  When  the  growths  are  situated  at  the  ex- 
ternal meatus,  or  just  within  the  urethra,  and  are  so  numerous 
as  to  form  a  kind  of  belt  or  zone  around  its  circumference,  the 
safest  plan  is  to  excise  the  aftected  portion  of  the  canal,  includ- 
ing the  mucous  membrane  and  sul)mucous  connective  tissue,  and 
approximate  the  edges  b}'"  sutures.  The  bleeding  which  follows 
the  operation,  and  which  is  occasionalh^  quite  profuse,  is  readilj- 
stanched  by  pressure  with  a  tent  and  compress  wet  with  a  strong 
solution  of  alum  or  gallic  acid.  Retention  of  urine  sometimes 
ensues,  and  has  to  l)e  met  with  the  catheter. 

The  removal  of  these  tumors  is  sometimes  efl:ected  l)y  ligature. 
The  operation  is  both  awkward  and  painful,  and,  worse  than  all, 
is  seldom  effectual,  a  portion  of  the  excrescence  being  usually 
left  behind,  thus  favoring  repuUulation.  Should  it  be  preferred, 
great  care  should  bo  taken  to  apply  the  ligature  as  closely  as 
possible  to  the  base  of  the  morbid  growth,  and  to  draw  it  with 
sufficient  firmness  to  insure  its  speedy  strangulation.  Detach- 
ment usually  takes  place  in  three  or  four  days.  A  practical 
precaution,  of  some  consequence  in  using  the  ligature,  is  that  it 
should  not  be  too  fine  or  delicate,  nor  drawn  too  tightly,  other- 
wise it  will  cut  through  the  tumor  prematurely. 

Any  reproductive  tendency  that  may  manifest  itself  after 
these  operations,  should  be  counteracted  by  chromic  acid,  nitrate 
of  silver,  or  by  a  solution  of  this  substance  in  nitric  acid,  by  the 
tincture  of  the  chloride  of  iron,  or,  what  I  prefer,  l>y  the  tincture 
of  iodine. 


CHAPTER    XI. 

FOREIGN  BODIES  IN  THE  URETHRA. 

The  urethra  is  liable  to  the  introduction  and  lodgment  of 
foreign  bodies,  which  difier  very  much  in  their  character, 
according  to  the  source  from  wliich  they  are  derived.  Con- 
sidered with  reference  to  this  point,  they  may  be  approi)riately 
arranged  under  two  heads :  1st,  those  which  descend  from  the 
urinary  bladder,  or  which  are  developed  in  the  urinary  canal 
itself;  and  2dly,  extraneous  substances  forced  into  the  urethra 
througli  its  external  oritice. 

1.  Foreign  Bodies  which  descend  from  the  Bladder,  or  are 
developed  in  the  Urethra.  —  Most  of  the  substances  which 
descend  into  the  urethra  from  the  bladder  are  organic  or  inor- 
ganic concretions,  which  are  developed  either  in  the  latter 
organ,  in  the  prostate,  or  in  the  kidneys.  Soti»etimes,  however, 
they  consist  of  articles  which  were  originally  admitted  through 
the  urethra,  and  wliich  have  afterwards,  in  consequence  of  the 
force  impressed  upon  them  by  the  bladder  or  the  stream  of 
urine,  taken  a  retrograde  course.  A  bean,  a  bit  of  catheter, 
the  end  of  a  bougie,  a  needle,  or  a  piece  of  wood,  has  sometimes 
met  with  such  a  fate.  A  ball,  a  portion  of  wadding,  or  a  frag- 
ment of  bone,  accidentally  introduced  into  the  bladder,  may 
likewise  pass  from  this  organ  into  the  urethra,  and  become 
impacted  in  it. 

Secondly,  the  concretion  may  be  developed  in  the  urethra 
itself.  The  occurrence  is  rare ;  but  that  it  is  possible  is  shown 
bit  by  the  fact  that  a  foreign  body,  such  as  a  piece  of  straw  or  a 
of  bougie,  lodged  in  this  canal,  has  sometimes  become  speedily 
inerusted  with  sabulous  matter,  and  that  calculi  have  occasion- 
ally formed  in  a  perineal  tistule,  the  scrotum,  and  the  prepuce. 
The  develo[)ment  is  favored  by  the  existence  of  an  abnormal 
pouch  of  the  urethra,  or  by  an  organic  stricture  attended  with 
dilatation  and  ulceration  of  the  canal  behind  the  obstru(.'tion. 
The  concretions  do  not  seem  to  differ,  in  any  essential  particular, 


FOREIGN    BODIES    IX    THE    URETHRA.  537 

as  it  respects  their  pliysical  and  elieinical  properties,  from  tliose 
Avliich  form  in  tlie  bladder  and  kidneys.  They  are  usually 
diminutive ;  and  they  vary  in  their  number  from  one  to  live  or 
six. 

A  very  extraordinary  example  of  calculus  of  the  urethra  is 
mentioned  by  the  late  Professor  Miitter,  in  his  Notes  to  Liston's 
Operations  of  Surgery.  The  patient  was  a  young  man  of  twenty, 
of  very  feeble  health,  and  with  evidence  of  chronic  inflammation 
of  the  bladder.  The  concretion,  which  was  immovably  lixed 
in  its  situation,  hard,  smooth,  and  about  the  diameter  of  an 
ordinary  pipe-stem,  was  accurately  moulded  to  the  urethra,  and 
reached  fi-om  Avithin  an  inch  of  the  external  orifice  of  the  canal 
to  the  neck  of  the  bladder. 

A  urinary  concretion,  or  any  other  foreign  body  forced  from 
the  bladder  into  the  urethra,  may  lodge  in  any  portion  of  this 
canal,  from  its  commencement  to  its  termination,  and  the 
symptoms  awakened  by  its  presence  will  not  vary  essentially 
whatever  may  be  the  part  affected.  When  the  substance  is 
permanently  fixed,  it  generally  attains  a  greater  magnitude  in 
the  membranous  division  of  the  canal  than  in  any  other,  simply 
because  this  portion  of  the  canal  is  naturally  very  dilatalde. 
Sometimes,  however,  large  concretions  form  at  the  prostatic 
portion,  the  sinus  of  the  bulb,  and  the  navicular  fossa. 

The  passage  of  a  calculus  from  the  bladder  along  the  urethra 
is  frequently  i)roductive  of  great  inconvenience  and  distress. 
The  intromission  is  generally  sudden  and  unexpected,  taking 
place  while  the  patient  is  engaged  in  micturition.  It  is 
instantly  followed  by  an  interruption  of  the  stream  of  urine, 
an  urgent  desire  to  empty  the  bladder,  severe  straining,  more 
or  less  pain,  and  a  sense  of  burning  or  tearing  in  the  urethra. 
If  the  sul)stance  is  small,  it  may  be  expelled  in  a  few  minutes, 
perhaps  during  a  new  ettbrt  at  micturition  followed  by  imme- 
diate and  permanent  relief.  If,  on  the  contrary,  it  is  dispro- 
portionately bulky,  it  may  be  arrested  for  several  hours  or  even 
days,  and  g-ive  rise  to  severe  suffering,  accompanied  by  partial 
orcomplet'e  retention  of  lirine,  painful  erections,  and  probably 
also  by  slight  hemorrhage  from  laceration  of  the  mucous  mem- 
brane."^ AVhen  the  calculus  is  of  extraordinary  size,  it  can  hardly 
fail  to  lodge  permanently,  and  to  lead  to  all  the  distress,  both 


588  FOREIGN    BODIES    IX    THE    URETHRA. 

local  and  constitutional,  which  is  always  sure  to  result  from  the 
protracted  obstruction  of  an  important  excretory  tube. 

The  s^Mnptonis  which  attend  the  passage  of  a  calculus  along 
the  urethra  may  be  simulated  b}'  those  produced  by  other  causes, 
and  are,  therefore,  of  no  positive  value  in  determining  the 
nature  of  the  accident.  To  cstal)lish  the  diagnosis,  it  is  neces- 
sar\^  to  institute  a  careful  examination  with  the  finger  and  the 
catheter.  When  the  foreign  body  occupies  the  spongy  portion 
of  the  urethra,  the  finger,  applied  to  the  lower  surface  of  the 
penis,  will  generally  readily  detect  it,  and  give  the  surgeon  a 
correct  idea  both  of  its  volume  and  configuration.  The  same 
means  will  enable  him  to  ascertain  whether  it  is  fixed  or  mova- 
ble. When  the  substance  is  situated  farther  back,  as  in  the 
membranous  or  prostatic  portion,  the  exploration  must  be  con- 
ducted with  the  finger  in  the  rectum,  otherwise,  especially  if 
it  be  very  small,  it  will  be  impossible  to  feel  it,  on  account  of 
the  great  thickness  of  the  soft  parts. 

When  the  foreign  bod}'  cannot  be  detected  with  tlie  finger,  or 
where  an^^  doubt  remains  respecting  the  real  nature  of  the 
obstruction,  recourse  must  be  had  to  the  catheter.  The  best  in- 
strument, for  this  jnirpose,  is  a  silver  one,  well  rounded  at  the 
vesical  extremity,  and  of  medium  size.  This  is  introduced  in 
the  usual  manner,  and  carried  on  towards  the  bladder  as  slowly 
and  as  gentl}-  as  possible.  If  the  obstruction  has  been  caused 
by  the  presence  of  a  calculus,  the  contact  of  the  catheter  with 
the  foreign  bodj'  will  produce  a  peculiar  sound  and  a  rubbing  or 
grating  sensation,  which  no  one,  practised  in  such  examinations, 
can  mistake.  The  diagnosis  is  established.  Some  idea  may  be 
obtained  concerning  the  volume  of  the  concretion  by  observing 
whether  the  instrument  is  completelj'  arrested  by  it,  or  whether 
it  slips  between  it  and  the  walls  of  the  urethra.  In  making  this 
exploration,  care  should  be  taken,  by  inserting  the  finger  into 
the  rectum,  that  the  foreign  substance  be  not  pushed  back  into 
the  bladder  ;  an  occurrence  always  to  be  deprecated,  unless  it  is 
rendered  absolutelj-  necessary  in  consequence  of  retention  of 
urine,  or  the  want  of  proper  instruments  for  performing  extrac- 
tion. It  is  worthy  of  remark,  that,  f\dien  the  calculus  has 
escaped  from  the  urethra  and  lodged  in  the  subjacent  structures, 
the  instrument  may  fail  to  detect  it,  even  when  it  is  of  large  size. 

When  a  calculous  concretion  has  been  developed  in  the  urethra, 


FOEEIGN    BODIES    IN    THE    URETIIEA.  539 

or  lias  been  forced  into  it  from  the  bladder  and  retained  there 
for  a  long  time,  its  tendency  is  to  increase,  by  the  addition  of 
new  deposits  from  the  earthy  salts  of  the  urine.  The  extent  to 
which  this  augmentation  may  reach  is  variable,  as  are  also  the 
efitects  to  -which  it  may  lead,  as  it  respects  the  surrounding 
tissues.  A  concretion,  weighing  five  or  six  ounces,  has  occa- 
sionally been  developed  in  this  situation,  and  given  rise  to  all 
the  symptoms  of  vesical  calculus.  Long  before  it  attains  such 
a  bulk,  the  foreign  substance,  producing  ulcerative  absorption, 
leaves  the  canal  of  the  urethra,  and  forms  a  sort  of  cul-de-sac  by 
the  expansion,  thickening,  and  condensation  of  the  circumjacent 
structures. 

A  calculus,  permantly  impacted  in  the  neck  of  the  bladder, 
has  been  known  to  cause  complete  absorption  of  the  prostate 
gland,  and  great  dilatation  of  the  corresponding  portion  of  the 
urethra.  The  foreign  body,  in  this  case,  being  situated  partly 
in  the  bladder  and  partly  in  the  urethra,  sometimes  attains  an 
extraordinary  volume,  and  presents  a  most  bizarre  appearance, 
especially  when  it  extends  several  inches  into  the  latter  canal. 
The  symptoms  are  those  of  ordinary  vesical  calculus,  except  that 
there  is  not  so  much  interruption  to  the  stream  of  urine,  because 
of  the  immovable  condition  of  the  concretion,  and  because  of 
there  being  also,  for  the  same  reason,  more  frequently  inconti- 
nence, in  consequence  of  the  loss  of  power  of  the  sphincter 
muscle. 

Finally,  a  calculus,  after  having  remained  in  the  urethra  for 
an  indefinite  period,  sometimes  effects  its  own  expulsion.  This 
it  does  by  exciting  absorption  of  the  surrounding  parts,  which 
gradually  progresses  until  all  the  tissues  give  way,  save,  perluqis, 
the  cutaneous,  which  at  length  yields  under  a  violent  effort  at 
micturition.  Or,  instead  of  this,  the  skin  ulcerates  at  the  most 
prominent  portion  of  the  tumor,  and  exposes  the  foreign  body 
to  such  an  extent  as  that  it  may  be  easily  extracted. 

The  treatment  of  urethral  calculi  must  necessarily  be  iivflu- 
enced  by  a  variety  of  circumstances,  some  of  which  hardly  admit 
of  precise  detail.  When  the  foreign  body  is  lodged  in  the  poste- 
rior portion  of  the  canal,  behind  the  triangular  ligament,  and 
is  so  large  as  to  obstruct  the  flow  of  urine,  the  safest  plan  is  to 
push  it  back  into  the  bladder,  whence  it  came.  For  this  pur- 
pose a  full-sized  silver  catlieter,  witli  a  small  curve,  open  at  the 


540  FOREIGN    BODIES    IX    THE    URETHRA. 

extremity,  and  provided  with  an  obturator,  and  resemblino; 
the  instrument  represented  at  page  116,  is  used ;  this  is  intro- 
duced in  the  usual  manner,  when  the  obturator  is  removed, 
and  the  o])en  beak  then  gently  but  firmly  pressed  against  the 
concretion,  at  the  same  time  that  the  finger  is  applied  uiton  the 
perineum,  to  prevent  the  formation  of  a  false  passage.  A  small 
instrument  is  unsuitable,  inasmuch  as  its  point  might  pass  be- 
tween the  calculus  and  the  wall  of  the  urethra.  Any  spasmodic 
action  that  may  exist,  whether  in  the  canal  itself,  or  in  tlie  mus- 
cles b}'  which  it  is  surrounded,  should  be  combated  by  chloro- 
form. Unless  the  concretion  is  very  bulky,  rough,  or  curved, 
this  plan  will  seldom  fail,  and  should  always,  I  conceive,  be  pre- 
ferred to  tlie  more  uncertain  method  of  extraction. 

If,  on  the  contrary,  the  extraneous  body  is  comparatively 
small,  or  so  irregular  on  the  surface  as  to  enable  the  patient  to 
void  his  urine,  it  should  not  be  pushed  back  but  removed.  Delay 
here  is  of  little  consequence,  as  the  accident  is  rarely  attended 
with  much  sufi'ering,  and  the  surgeon  has  ample  time  to  prepare 
for  the  operation.  Before  resorting  to  extraction,  an  attempt 
should  be  made  to  favor  the  expulsion  of  the  concretion,  by 
dilating  the  portion  of  the  urethra  which  is  in  front  of  it,  by 
means  of  the  catheter  or  bougie.  This  process  has  been  success- 
ful in  more  instances  than  one.  Occasionallj'  extrusion  may  be 
eflected  b}'  injections  of  sweet  oil,  or  b}-  closing  the  meatus,  and 
holding  it  tightlj'  while  the  patient  is  making  a  powerful  ettbrt 
to  expel  his  urine,  at  the  same  time  that  pressure  is  aj)plied 
along  the  under  surface  of  the  urethra,  to  urge  on  the  foreign 
body. 

When  the  calculus  occupies  the  spongy  portion  of  the  canal,  it 
should  be  extracted,  whatever  may  be  its  size  or  form.  To  push 
it  back  into  the  bladder  woukl  be  difficult  and  hazardous,  on 
account  of  the  distance  at  which  it  is  situated,  and  the  curved 
direction  of  the  urethra,  to  say  nothing  of  the  violent  spasm 
which  such  an  attempt  is  calculated  to  awaken  in  the  perineal 
muscles. 

When  the  foreign  body,  whatever  be  its  situation,  is  so  firmly 
impacted  that  it  can  neither  be  expelled  by  the  powers  of  the 
patient,  nor  pushed  back  into  the  bladder,  extraction  is  neces- 
sary-. This  may  generalh'  be  ettected  when  the  concretion  is 
near  the  orifice  of  the  urethra,  or  in  that  portion  of  it  which 


FOREIGN    BODIES    IN    THE    URETHEA.  541 

corresponds  with  the  liead  of  the  penis,  by  very  simple  means, 
as  a  pair  of  narrow-bladed  dissecting  forceps,  or  even  the  fingers; 
but  the  reverse  is  often  the  case  when  it  is  lodged  far  back  in 
the  canal.  One  of  the  most  simple  contrivances  for  effecting 
onr  object,  under  such  circumstances,  is  the  wire-loop,  originally 
suggested  by  Marini.  This  consists,  as  the  name  implies,  of  a 
piece  of  smooth,  thin,  flexible  wire,  of  silver  or  copper,  bent  like 
a  hair-pin,  the  convex  extremity  of  which  is  passed  down  the 
urethra,  and  insinuated  behind  the  foreign  body,  which  is  then 
caught  and  drawn  out.  A  modification  of  this  instrument,  if 
so  it  deserves  to  be  styled,  was  made  by  Jules  Cloquet,  by 
adapting  to  it  a  silver  canula  with  a  side-screw,  in  order  the 
more  effectually  to  secure  the  calculus  after  it  has  been  seized 
by  the  Avire.  The  objection  to  this  instrument,  in  both  its  forms, 
is  the  difliculty  of  passing  it  behind  the  concretion,  which,  when 
large  enough  to  lodge,  usually  fills  up  the  entire  passage. 

When  these  simple  means  fail,  and  also  in  the  more  difficult 
forms  of  the  accident,  recourse  must  be  had  to  the  urethral  for- 
ceps, of  which  there  is  a  great  variety.  Several  of  these  instru- 
ments are  represented  in  the  annexed  drawings,  which  preclude 

Fiii.  162. 


Articulated  Scoop  of  Bonaet. 

the  necessity  of  any  labored  description.  The  one  to  which  I 
give  the  preference,  both  on  account  of  its  simplicity  and  its 
hai)py  adaptation  to  the  end  proposed,  is  the  articulated  scoop 
of  Bonnet,  of  Lyons  ;  it  is  armed  w^ith  a  stylet,  and  is  furnished 
Avith  a  head  for  seizing  and  fixing  the  foreign  body.  The  in- 
strument, well  oiled,  is  introduced  shut,  until  it  comes  in  contact 

Fi?.  163. 


Hunter's  Forceps. 


with  the  concretion,  when  its  blades  are  expanded  over  it  :  the 
extraction  beino-  effected  in  the  most  slow  and  gentle  manner. 


542 


FOREIGN  BODIES  IX  THE  URETHRA. 


Fig.  164.  to  prevent  injuiy  of  the  mucous  membrane. 

Fig.  163  represents  Hunter's  forceps,  as  im- 
improved  by  modern  surgeons.  Mathieu's 
instrument,  fig.  164,  is  probably  the  best  of 
its  class. 

Breaking  or  crushing  is  applicable  only 
when  the  calculus  is  soft  or  friable ;  but  as 
this  can  hardly  ever  be  known  beforehand, 
it  is  seldom  available.  The  operation,  more- 
over, is  seldom  safe,  however  carefully  per- 
formed, being  liable  to  be  followed  by  lacera- 
tion of  the  mucous  membrane,  infiltration  of 
urine,  and  severe  inflammation.  It  may  be 
best  done  with  the  delicate  urethral  litho- 
trite  of  Reliquet,  although  the  insertion  of 
the  female  blade  behind  the  concretion  is  by 
no  means  easy.  When  the  calculus  is  seated 
in  the  spong}^  portion  of  the  urethra,  Reli- 
quet' advises  that  the  instrument  be  brought 
in  contact  with  it,  the  urethra  behind  it 
having  been  previously  compressed  by  an 
assistant  to  steady  it,  when  by  bending  the 
penis  and  keeping  the  convexity  of  the  blade 
in  contact  with  the  side  of  the  urethra,  the 
beak   may  be  slipped  behind  the  concretion.     The  male  blade 


Matliieu'-s  Forceps. 


Fiff.  105. 


Fii?.  IGG. 


Fi-.  167. 


lulrodncti  in  of  Lilhotrite  and  seizure  of  the  Slone. 

'  Traite  des  Operations  des  Voies  Urinaires,  Paris,  1871,  p.  586. 


FOREIGN-    BODIES    IX    THE    URETHRA.  543 

being  then  protruded  the  concretion  is  broken  up.  These  man- 
(DGUvres  are  represented  in  figs,  165,  166,  and  167. 

In  the  remarkable  case  of  Dr.  Mutter  previously  referred  to, 
that  gentleman  succeeded  in  freeing  the  urethra  by  cutting 
off  daily  a  piece  of  the  stone,  with  a  pair  of  small,  strong, 
slightly  curved,  sharp-cutting  forceps,  expresslj'  constructed  for 
the  purpose.  As  the  urethra  was  very  irrital)le,  the  operation 
was  attended  with  some  pain,  but  nothing  serious  ensued,  and 
in  a  short  time  the  entire  cylinder  was  removed. 

Excision,  which  becomes  necessary  when  extraction  fails, 
varies  according  to  the  situation  of  the  foreign  body.  AVhen 
the  concretion  is  lodged  deepl}*,  as  in  the  prostatic  or  membran- 
ous part  of  the  canal,  it  is  performed  very  much  after  the  manner 
of  Celsus,  in  cutting  on  the  gripe,  as  it  was  called.  The  rectum 
having  been  thoroughly  emptied  by  an  enema,  and  the  patient 
placed  as  in  the  operation  of  lithotomy,  the  surgeon  introduces 
the  fore  and  middle  finger*  of  the  left  hand,  well  oiled,  into  the 
anus,  and  uses  them  to  push  the  stone  forward,  to  make  it  pro- 
trude and  form  a  tumor  in  the  perineum.  An  incision  is  then 
made,  either  of  a  lunated  shape,  as  in  the  bilateral  method,  or, 
what  is  better,  because  more  easy  and  simple,  in  the  direction  of 
the  raphe  of  the  perineum.  AVhen  the  concretion  is  fully  ex- 
posed, it  may  either  be  pressed  out  with  the  fingers,  or  extracted 
with  a  bhyit-ljook  or  pair  of  forceps.  In  performing  this  opera- 
tion, care  must  be  taken  to  guard  the  rectum. 

When  the  calculus  is  impacted  in  the  navicular  fossa,  its  re- 
moval is  easily  effected  by  incising  the  lower  part  of  the  urethra 
where  this  canal  corresponds  with  the  head  of  the  penis.  When 
the  foreign  body  lies  in  that  portion  of  the  urethra  which  corre- 
sponds with  the  scrotum,  incision  must  be  practised  with  great 
caution,  lest  it  be  followed  by  infiltration  of  urine  and  all  the 
bad  consequences  of  such  an  accident.  In  such  a  case,  I  would 
advise  immediate  cauterization  of  the  wound  with  nitrate  of 
silver,  and  an  avoidance  of  micturition  for  ten  or  twelve  hours, 
to  favor  the  deposit  of  lymph. 

2.  Foreign  Bodies  Introduced  from  Without.— Of  foreign 
bodies  introduced  into  the  urethra  from  Avithout,  the  number 
and  variety  are  quite  considerable.  The  occurrence  is  some- 
times tlie  result  of  accident;  but,  more  frequently,  it  takes  place 
throuo-h  desio-n,  either  of  the  patient  himself,  or  of  mischievous 


544  FOKEIGX    BODIES    TX    THE     URETHKA. 

and  wicked  persons,  who  take  advantage  of  tlie  helpless  state 
of  their  intended  victim.  Bits  of  catheters,  bougies,  quills,  pipe- 
stems,  wood,  straw,  and  other  substances  have  been  accidentally 
lodged  in  the  urethra  by  individuals  endeavoring  to  draw  oft" 
their  urine,  relieve  a  stricture,  or  provoke  onanism.  Females, 
apparently  from  mere  wantonness,  or  a  desire  to  excite  sympathy 
and  commiseration,  often  introduce  pebbles,  cherry-stones, 
chicken-bones,  bits  of  brick,  pins,  needles,  and  other  articles, 
into  the  urethra. 

Foreign  bodies,  introduced  from  without,  produce  various 
effects,  according  to  the  manner  in  which  they  are  inserted,  their 
nature,  the  distance  which  they  have  travelled,  and  the  period 
of  their  sojourn.  There  is  one  feature  which  they  all  possses  in 
common,  namel}^  a  remarkable  propensity  to  migrate  to  the 
bladder,  no  matter  what  may  be  their  form,  size,  or  composition. 
The  bladder,  favored  by  the  peristaltic  action  of  the  urethra, 
manifests,  so  to  speak,  in  all  cases  of  this  kind,  a  disposition  to 
swallow  the  foreign  body,  or  to  suck  it  in.  In  some  cases  the 
extraneous  substance  becomes  impacted,  and  remains  in  the  canal 
for  an  indefinite  period,  perhaps  for  many  years,  attended,  it  may 
be,  with  little  inconvenience  or  functional  disturbance.  Occa- 
sionally, it  forms  the  nucleus  of  a  urinarj'  concretion,  or  its 
surface  becomes  incrusted  with  earthy  matter.  When  bulky, 
it  gives  rise  to  retention  of  urine,  with  inflammation  of  the 
urethra,  severe  pain,  morbid  erections,  frequent  micturition, 
rigors,  and  high  constitutional  disorder.  Hemorrhage  is  liable 
to  attend  when  the  foreign  substance  has  an  unusually  rough 
surface,  or  when  it  has  been  rudely  inserted. 

Finally,  it  occasional!}'  happens,  as  was  previously  stated,  that 
the  escape  of  a  concretion  is  }»revented  by  an  organic  stricture. 
When  the  case  is  urgent,  or  admits  of  no  delay,  in  consequence 
of  retention  of  the  urine,  relief  must  be  afforded  either  by  divid- 
ing the  stricture  from  wdthin,  and  then  extracting  the  calculus 
in  the  usual  manner,  or,  when  this  is  impracticable,  by  making 
an  incision  into  the  canal,  embracing  both  the  stricture  and  the 
foreign  body. 

Much  tact  and  ingenuity  are  often  required  in  extracting  a 
foreign  bod}-  introduced  from  without.  This  is  especially  the 
case  when  it  has  broken  off  low  down  in  the  passage,  or  when 
it  has  pierced  its  walls.     Much  difHcultv  mav  also  result  from 


FOREIGN    BODIES    IX    THE     URETHRA.  545 

the  peculiar  nature  or  shape  of  the  article.  Thus,  a  hair-pin, 
inserted  head  foremost,  and  pushed  out  of  sight,  might  greatly 
perplex,  and  completely  baffle,  a  man  unaccustomed  to  think  for 
himself,  or  rely  upon  his  own  resources.  Boinet,  a  French  sur- 
geon, being  called  to  a  case  of  this  kind,  had  recourse  to  the 
following  ingenious  expedient:  Taking  hold  of  the  penis,  he 
bent  this  organ  strongly  upwards,  at  the  same  time  that  he  made 
firm  pressure  upon  the  head  of  the  pin,  to  prevent  it  from  reced- 
ing. By  this  manoeuvre  the  points  of  the  instrument  were  forced 
through  the  lower  wall  of  the  urethra;  the  two  branches  were 
then  separated  transversely,  when  one  of  them  was  cut  off,  and 
the  other  pulled  out.  The  operation  lasted  only  a  few  minutes, 
and  was  not  followed  by  any  unpleasant  effects. 

The  late  Mr.  Averj^  of  London,  by  the  following  simple 
method,  promptly'  succeeded,  on  one  occasion,  in  extracting  from 
the  urethra  of  a  gentleman,  a  hair-pin  which  had  been  pushed 
down  the  canal  about  an  inch  and  a  half,  the  two  points  looking 
towards  its  orifice.  Having  firmly  grasped  the  pin,  he  squeezed 
tlie  two  ends  of  it  together,  while  with  the  other  hand  he  intro- 
duced a  sti'aight  tube — a  piece  of  catheter — which  passed  over 
the  end  of  the  pin,  which  followed  the  instrument  as  it  was 
withdrawn,  the  elasticity  of  it  keeping  it  firmly  in  its  place 
when  the  pressure  applied  to  it  through  the  urethra  was  taken 
off. 

When  the  foreign  substance  is  of  a  simple  character,  as  the 
stalk  of  a  plant,  a  toothpick,  a  needle,  or  a  pin,  it  may,  if  it  have 
not  slipped  too  far  back,  be  extracted  with  a  pair  of  delicate 
forceps,  as  those  represented  in  fig.  164.  To  render  the  success 
more  certain,  the  penis  should  be  held  horizontally,  and  sliglitly 
on  the  stretch,  otherwise  it  may  be  difficult  to  expand  the  blades 
of  the  instrument  over  the  extremity  of  the  intruder.  Care 
should  also  be  taken  that  the  force[)S  do  not  pass  between  the 
substance  and  the  wall  of  the  urethra.  Another  precaution,  not 
to  be  overlooked,  is  to  apply  pressure  just  behind  the  foreign 
body,  to  prevent  it  from  receding  during  the  attempts  at  extrac- 
tion. Similar  substances  may  be  entrapped  between  the  blades 
of  expanding  instruments,  as  Thompson's  divulsor,  as  suggested 
by  Dr.  Keyes,  of  New  York. 

35 


CHAPTER  XII. 


LACERATION  OF  THE  URETHRA. 


Laceration,  or  rupture,  of  the  urethra  is  produced  by  two 
varieties  of  causes,  the  one  acting  from  without,  the  other  from 
within.  Under  the  first  may  be  comprised  falls,  blows,  and 
kicks  upon  the  perineum,  or  the  perineum  and  the  penis ;  under 
the  second,  the  violent  straining  which  attends  micturition  in 
stricture,  injury  done  by  the  lodgment  of  a  calculus,  and  the  rude, 
forcible,  or  injudicious  use  of  catheters,  bougies,  and  sounds. 
Laceration  of  this  canal  has  occasionally 
taken  place  under  a  violent  erection,  espe- 
cially if  the  penis,  while  in  this  condition, 
be  struck  accidentally  against  a  hard, 
resisting  body.  It  has  also  been  known 
to  happen  during  coition  and  during  con- 
valescence, after  attacks  of  fever. 

In  the  majority  of  instances,  the  lacera- 
tion is  caused  b}^  falls  from  a  considerable 
height,  in  which  the  perineum  strikes 
against  some  sharp,  angular,  or  projecting 
body,  while  the  thighs  are  more  or  less 
separated  from  each  other.  From  the  pecu- 
liar character  of  their  occupation,  sailors, 
masons,  carpenters,  painters,  house-cleaners, 
coachmen,  and  teamsters  are  more  prone  to 
this  kind  of  injury  than  any  other  classes 
of  individuals.  Sometimes  the  laceration 
is  occasioned  by  a  blow  or  kick  upon  the 
perineum,  from  the  foot  of  a  man  or  a  horse ; 
and  it  may  also  be  produced  by  the  person 
being  thrown  forcibly  forward  on  the  pom- 
mel of  his  saddle.  Laceration  of  the  urethra 
by  balls  is  usually  complicated  by  wounds  of  the  scrotum, 
testes,  thighs,  buttocks,  groin,  perineum,  and  penis,  as  in  fig. 
168,  taken  from  a  specimen  in  the  Army  Medical  Museum. 


>liot  rerriiia'''on  of  tlie 
Uretliia. 


LACERATIOX  OF  THE  UEETHRA.  547 

Of  the  internal  causes  of  laceration  of  the  urethra,  the  most 
common  are  vesical  calculi,  bougies,  and  catheters.  After  litho- 
trity,  serious  injury  is  often  inflicted  by  sharp,  angular  frag- 
ments of  stone  impinging  against,  and  rupturing  the  mucous 
membrane  ;  and  the  same  circumstance  occasionally  occurs  when 
a  small,  but  rough  calculus,  in  its  attempt  at  extrusion,  becomes 
impacted  in  the  posterior  portion  of  the  canal.  The  mischief 
which  is  sometimes  done  to  the  urethra  in  the  rude  introduction 
of  the  catheter,  bougie,  and  sound,  is  familiar  to  every  one. 

The  laceration  varies,  as  to  its  seat,  according  to  the  nature  of 
the  vulncrating  body,  or  the  character  of  the  exciting  cause. 
AVhen  it  results  from  a  blow,  fall,  or  kick  upon  the  perineum,  it 
usually  occurs  on  a  level  with  the  deep  perineal  fascia,  in  which 
location  the  rent  is  made  by  the  urethra  being  violently  driven 
against  the  subpubic  ligament ;  occasionallj",  it  is  situated  be- 
hind this  point ;  and  sometimes,  although  rarely,  it  is  met  with 
in  the  spongy  portion  of  the  canal.  When  the  rupture  is  caused 
by  tlie  passage  of  a  calculus,  or  of  an  instrument,  it  may  be  seated 
in  any  region  of  the  urethra,  from  tlie  neck  of  the  bladder  to  the 
external  orifice. 

There  is  no  uniformity  in  regard  to  the  extent  of  this  injury. 
While  in  some  instances  it  is  extremely  slight,  presenting  itself 
perhaps  merely  in  the  iorm  of  a  minute  fissure,  slit,  or  crevice, 
in  others  it  is  so  great  as  to  embrace  one-half,  two-thirds,  or  even 
the  entire  circumi'erence  of  tlie  tube.  In  the  latter  case,  the  ends 
of  the  divided  canal  frequently  lose  their  apposition,  and  thus 
oppose  a  serious,  if  not  an  insurmountable,  barrier  to  the  intro- 
duction of  the  catheter.  The  laceration  may  be  limited  to  the 
mucous  membrane,  or  it  may  involve  along  with  it  all  the  tissues 
which  intervene  between  the  canal  and  the  external  surface, 
according  to  its  seat,  and  the  nature  of  the  vulnerating  body. 
Finally,  it  may  be  solitary  or  multiple,  longitudinal,  transverse, 

or  oblique. 

The  symptoms  of  tliis  afiection  are  generally  suflicieutly 
characteristic.  The  most  [)rominent  are,  pain  in  the  afiected 
part,  hemorrhage,  inability,  with  constant  desire,  to  void  the 
urine,  or  the  discharge  of  this  fluid  in  a  small  and  imperfect 
manner,  discoloration  and  swelling  of  the  perineum,  or  of  the 
perineum,  scrotum,  and  penis,  and  great  difliculty,  if  not  utter 
impossibility,  of  introducing  the  catheter.     The  patient  is  weak 


548  LACERATIOX    OF    THE    URETHRA. 

and  faint,  perhaps  sick  at  the  stomacli,  and  labors  under  all  the 
effects  of  a  severe  shock. 

Tlie  pain  is  usually  in  direct  proportion  to  the  extent  and 
violence  of  the  accident.  It  is  of  an  acute,  sharp,  cutting 
character,  is  generally  circumscribed  or  limited  to  the  seat  of 
the  injury,  and  is  greatly  aggravated  by  the  passage  of  the  urine, 
by  motion,  and  by  pressure  upon  the  perineum.  It  is  not  in- 
termittent, but  constant,  and  is  sometimes  compared  by  the 
patient  to  the  sensation  produced  by  the  contact  of  molten  lead. 
Although  originally  circumscribed,  it  soon  extends  to  the  cir- 
cumjacent parts,  as  the  testicles,  groins,  thighs,  anus,  and  the 
bladder,  and  becomes  so  severe  as  not  to  allow  the  poor  sufferer 
a  moment's  comfort. 

The  hemorrhage  varies  in  quantity  from  a  few  drops  to  a 
number  of  ounces,  according  to  the  extent  of  the  injury  sus- 
tained b}'  the  urethra  and  the  circumjacent  textures.  The  loss 
of  a  pint  of  blood  soon  after  the  accident  is  no  unusual  occur- 
rence. The  discharge,  which  is  generally  transient,  sometimes 
continues  for  a  number  of  days,  and  is  always  aggravated  or  re- 
produced at  every  attempt  to  introduce  the  catheter.  Occasion- 
ally the  blood,  instead  of  issuing  at  the  external  orifice  of  the 
urethra,  escapes  at  the  abnormal  opening,  lodges  in  the  surround- 
ing connective  tissue,  or  passes  back  into  the  bladder,  where  it 
is  either  retained,  or,  as  most  commonly  happens,  dissolved,  and 
excreted  along  with  the  urine. 

Few  patients  affected  with  rupture  of  the  urethra,  are  able  to 
void  their  urine  with  anything  like  their  accustomed  facility. 
On  the  contrary,  there  is  usually  a  great  deal  of  difficulty,  ac- 
companied with  excessive  pain  and  straining,  and  a  constant 
desire  to  relieve  the  bladder.  In  many  cases,  indeed,  there  is 
complete  retention  from  the  very  beginning,  caused  either  by 
the  loss  of  apposition  of  the  divided  ends  of  the  canal,  by  the 
presence  of  coagulated  blood,  or  by  the  disabled  condition  of  the 
bladder  itself.  Sometimes,  again,  although  rarely,  there  is  total 
suppression  of  urine. 

The  discoloration  of  the  affected  part  may  occur  instantly,  or 
not  under  a  few  hours.  It  varies  from  light  red  to  deep  purple 
or  black,  and  involves  not  only  the  perineum,  but  frequently 
also  the  scrotum  and  the  penis.  The  immediate  cause  of  this 
symptom  is  an  extravasation  of  blood  into  the  connective  tissue. 


LACERATION  OF  THE  URETHRA.  549 

the  quantity  of  which  varies,  in  difterent  cases,  from  a  few 
drachms  to  several  ounces.  When  considerable,  it  must  neces- 
sarily lead  to  proportionate  distention  of  the  affected  region, 
which  is  still  further  increased,  in  a  short  time,  b}'  the  ordinaiy 
products  of  inflammation.  Although  there  are  few  eases  of 
laceration  of  the  urethra  by  external  violence  in  which  there  is 
not  some  degree  of  discoloration  of  the  integuments,  it  is  worthy 
of  remark  that  the  parts  occasionally  present  an  entireljMiatural 
appearance. 

If  an  attempt  be  made  in  this  affection  to  draw  off  the  urine, 
the  catheter  wnll  either  not  enter  the  bladder  at  all,  or  it  will 
meet  with  more  or  less  resistance  at  the  seat  of  the  injury.  Its 
arrival  at  this  point  will  be  indicated  by  a  peculiar  grating  sen- 
sation, which  no  experienced  hand  can  possibly  mistake.  When 
the  laceration  is  considerable,  the  extremity  of  the  instrument 
will  be  apt  to  take  a  wrong  direction,  or  to  become  entangled 
by  the  edges  of  the  wound.  If  the  canal  be  completely  severed, 
and  the  divided  ends  have  lost  their  parallelism,  the  greatest 
difhculty  will  be  experienced  in  performing  the  operation;  and, 
in  many  instances,  no  surgeon,  however  skilful,  will  be  able  to 
succeed.  Should  the  instrument  fortunately  reach  the  bladder, 
its  withdrawal  will  generally  be  followed  by  a  renewal  of  the 
hemorrhage. 

Another  bad  consequence  of  laceration  of  the  urethra,  espe- 
cially when  produced  by  external  causes,  is  extravasation  of 
urine  into  the  surrounding  connective  tissue.  When  tlie  acci- 
dent occurs  in  the  posterior  part  of  the  canal,  in  front  of  the 
triangular  ligament,  the  fluid  generally  distends  the  perineum, 
and  thence  proceeds  forwards,  underneath  the  dartos,  into  the 
scrotum  and  spongy  body  of  the  penis.  In  such  a  case,  violent 
inflammation,  often  followed  by  sloughing,  and  even  death,  is 
an  inevitable  result. 

When  a  man  has  received  a  fall,  blow,  or  kick  upon  the  peri- 
neum, or  the  genitals,  and  is  almost  immediately  after  seized 
with  a  sharp,  cutting,  or  burning  pain  in  the  region  of  the  injury, 
and  a  discharge  of  blood  from  the  urethra,  it  maybe  pretty 
positively  atiinned  that  ho  is  laboring  under  the  eflects  of  a 
laceration  of  this  canal.  The  diagnosis  is  fully  confirmed,  when, 
superadded  to  tliese  symptoms,  there  is  a  frequent  desire  to 
empty  the  bladder,  with  an  inability  to  pass  a  drop  of  water. 


550  LACERATION  OF  THE  URETHRA. 

The  peculiar  grating  sensation,  previously  alluded  to,  as  being 
communicated  to  the  hand  on  attempting  to  introduce  a  cathe- 
ter, is  another  valuable  sign,  almost  ot"  itself  characteristic  of 
the  nature  of  the  accident.  A  mere  contusion  of  the  urethra, 
unaccompanied  by  any  rupture,  is  easily  distinguished  from  the 
latter  affection  by  the  aljsonce  of  hemorrhage  and  of  the  severe 
burning  pain  which  results  from  the  contact  of  the  urine.  In 
neither  case  can  any  positive  conclusions  be  drawn  from  the 
character  of  the  constitutional  symptoms,  which  are  often  as 
severe  in  one  of  these  lesions  as  in  the  other. 

The  danger  of  this  lesion  is  usually  in  direct  proportion  to 
its  extent,  and  the  state  of  the  bladder  at  the  time  it  is  inflicted. 
If  the  laceration  is  considerable,  and  the  patient  has  not  made, 
water  for  some  time,  infiltration  will  be  almost  certain  to  occur, 
and  to  be  followed  bj'  all  the  mischief  which  the  fluid  is  capable, 
of  producing  whenever  it  comes  in  contact  with  tissues  which 
are  not  accustomed  to  its  presence.  The  usual  consequences  of 
such  an  accident  are,  severe  pain  and  swelling  of  the  affected 
parts,  retention  of  urine,  violent  rigors,  great  depression  of  the 
pulse,  delirium,  excessive  thirst,  and  constant  restlessness.  If 
the  parts  be  not  relieved  by  early  and  free  incisions,  they  soon 
fall  into  gangrene;  hiccough  and  subsultus  ensue,  and  the 
patient  dies  in  great  agony,  generally  before  the  eightli  day, 
and  sometimes  as  early  as  the  fourth  or  fifth. 

In  slight  cases,  the  prognosis  is  always  more  favorable;  but 
even  here  the  patient  can  scarcely  be  considered  as  being  out  of 
danger  as  long  as  there  is  any  possibility  of  urinary  infiltration. 
Apart  from  this  contingency,  a  wound  or  rent  of  the  urethra  is 
attended  with  no  more  hazard  than  a  similar  injury  in  any  other 
region  of  the  body  ;  it  heals  quite  as  readily,  and  does  not  give 
rise  to  any  more  suffering.  The  injury,  even  when  compara- 
tively slight,  is  sometimes  followed  by  great  contraction  of  the 
corresponding  portion  of  the  canal. 

In  laceration  of  the  urethra  by  balls,  the  danger  increases 
with  the  distance  of  the  injury  from  the  external  meatus,  on 
account  of  the  augmented  risk  of  infiltration  of  urine.  The 
usual  causes  of  death  after  this  class  of  injuries  are  well  sbown 
by  a  reference  to  the  experience  derived  from  our  late  war.  Of 
105  cases  of  shot  wounds  of  the  urethra,  22  were  fatal,  8  from 


LACERATION"  OF  THE  URETHRA.  551 

urinary  infiltration,  9  from  surgical  fever  and  profuse  suppura- 
tion, including;  3  complicated  by  fracture  of  the  tliigli-bone  ;  3 
from  hemorrhage  ;  and  1,  each,  from  phlebitis  and  tetanus.  Of 
the  cases  that  recovered,  26  were  affected  with  stricture,  and  38 
with  iistules,  of  which  16  involved  the  pendulous  urethra,  17 
the  scrotal  or  perineal  portion  of  the  canal,  and  5  the  deep  por- 
tion of  the  canal,  along  with  the  rectum. 

The  treatment  of  this  accident  must  be  prompt  and  decisive, 
otherwise  great,  if  not  irreparable  mischief  must  inevitably 
befall  both  part  and  system.  As  the  chief  danger  consists  in 
the  escape  of  the  urine  by  the  breacli  of  the  urethra  into  the 
connective  tissue  of  the  perineum  and  scrotum,  every  means 
calculated  to  obviate  such  a  calamity  should  be  instantly  put 
in  requisition.  If  the  rent  be  small,  the  first  thing  to  be  done 
is  to  endeavor  to  pass  a  catheter  into  the  bladder;  an  operation 
which  is  to  be  conducted  in  as  gentle  and  cautious  a  manner  as 
possible,  lest  the  point  of  tlie  instrument  be  intercepted  In'  the 
wound,  and  thus  take  a  wrong  direction.  The  catheter  should 
rather  be  over  than  under  the  ordinary  size,  so  that,  when 
introduced,  and  fixed  in  its  place,  it  may  slightly  distend  the 
parietes  of  the  canal,  and  thereb}''  prevent  the  urine  from  flow- 
ing between  the  contiguous  surfaces.  The  object  of  this  pro- 
ceeding is  to  carry  off  the  water  from  the  bladder  as  fast  as  it 
arrives  there,  without  permitting  it  to  come  in  contact  with  the 
lacerated  surface.  Unless  this  be  attained,  the  treatment  must 
not  be  thought  of,  much  less  employed.  The  instrument  used, 
may  be  of  silver  or  vulcanized  caoutchouc,  although  I  always 
myself  prefer  the  latter  on  account  of  the  less  necessity  for 
changing  it  after  it  has  been  some  time  in  the  bladder,  and  its 
adaptability  to  the  normal  curve  of  the  urethra. 

If,  on  the  contrary,  the  rent  be  very  extensive,  as  is  indicated 
by  the  hemorrhage  and  other  symptoms,  the  only  rational  treat- 
ment is  to  make  a  free  incision  into  the  part,  -to  aftbrd  a  free 
exit  to  the  urine,  which  will  otherwise  be  sure  to  insinuate 
itself  rapidly  into  the  connective  tissue  of  the  perineum  and 
scrotum.  The  operation  is  conducted  upon  the  same  principles 
as  that  of  external  urethrotomy,  without  a  guide.  If  the 
urethra  be  completely  and  cleanly  divided  across,  its  ends 
should   be  approximated  with  a  single   suture,  and   union  be 


552  LACERATION  OF  THE  URETHRA. 

favored  over  a  soft  gum  catlieter,  tlie  end  of  which  shouhl  be 
kept  open  so  as  to  afford  a  constant  escape  for  the  urine,  and 
prevent  its  passage  along  the  side  of  the  instrument.  Under 
ordinary  circumstances,  a  catheter  need  not  be  retained  in  the 
l)ladder;  but  after  the  more  acute  symptoms  have  subsided,  a 
full-sized  sound  should  be  passed  daily  to  guard  against  undue 
contraction  of  the  cicatrizing  wound. 

The  operation  here  referred  to  is  easy  of  execution,  and  indis- 
pensable to  the  safety  of  the  patient ;  it  places  him  at  once  in  a 
state  of  comparative  security,  by  p)reventing  urinary  infiltration, 
and  affording  nature  an  opportunity  of  repairing  the  breech  at 
the  least  possible  expense  of  time  and  suffering,  ^o  danger 
whatever  is  to  be  apprehended  from  its  performance ;  and  the 
wound  usually  heals  in  a  very  short  time,  without  the  aid  of 
any  dressing. 

If  some  hours  have  elapsed  since  the  occurrence. of  the  injury, 
as  not  infrequently  happens  when  the  patient,  from  ignorance 
or  other  causes,  neglects  to  send  for  surgical  aid,  and  it  be  appa- 
rent, from  the  nature  of  the  symptoms,  that  there  is  urinary 
infiltration,  no  time  is  to  be  lost  in  making  numerous  and  deep 
incisions  into  the  affected  parts.  A  free  outlet  must  be  afforded 
to  the  pent-up  fluid,  and  to  the  inflammatory  products  which 
so  soon  succeed  to  it,  otherwise  extensive  sloughing  and  even 
death  may  be  the  consequence.  Hesitancy,  in  a  case  of  this 
kind,  must  yield  to  decision;  tardiness  to  promptness;  timidity 
to  boldness.     The  patient  is  saved  or  lost  in  a  moment. 

The  treatment  above  mentioned,  as  applicable  to  the  various 
contingencies  connected  with  tliis  lesion,  may  often  be  advan- 
tageously aided  by  general  and  topical  bleeding,  purgatives, 
demulcent  drinks,  the  warm  bath,  anodynes,  fomentations,  and 
poultices.  Much  judgment  is  generally  required  in  the  adapt- 
ation of  particular  remedies  to  particular  eases.  When  infiltra- 
tion is  present,  depletion  is  usually  badly  borue,  and  should  be 
practised  with  the  greatest  circumspection. 

It  has  been  proposed  in  laceration  of  the  urethra,  followed  by 
obstinate  retention  of  urine,  to  puncture  the  bladder  through 
the  rectum  or  the  abdomen.  ^J'o  such  a  proceeding,  which  has 
unfortunately  been  too  often  carried  into  effect,  there  is  great 
objection;    for,  even  supposing  that  it  relieves  the  distended 


LACERATION  OF  THE  URETHRA.  553 

organ,  it  does  not  strike  at  the  main  evil,  the  urinary  infiltra- 
tion of  the  surrounding  parts.  It  is  hetter,  therefore,  always 
to  incise  the  atfected  tissues  as  freely  as  possihle,  cutting  down 
to  the  urethra,  and  laying  it  open  so  as  to  afford  full  vent  to 
the  urine. 

The  contraction  of  the  canal  which  sometimes  succeeds  to 
this  injury  is  to  be  managed  upon  the  same  principles  as  a 
traumatic  stricture. 


CHAPTER    XIII. 

MALFORMATIONS  AND  IMPERFECTIONS  OF  THE  URETHRA. 

The  urethra  is  liable  to  a  variety  of  malformations,  which, 
althouiih  exceedingly  rare,  ought,  nevertheless,  to  be  known,  on 
account  of  their  practical  relations.  The  most  common  of  these 
congenital  vices  are  1st,  malformations  of  the  external  meatus; 
2dly,  absence,  contraction,  or  obliteration  of  the  canal ;  3dly, 
duplicity  of  the  urethra ;  4thly,  changes  of  form  ;  and  othly, 
deviations  from  the  normal  direction. 

1.  The  urinary-  meatus  is  occasionally  situated  considerably 
higher  up  or  lower  down  than  in  tlie  normal  state  ;  and  in  some 
instances,  and  these  are  by  no  means  infrequent,  it  is  placed 
upon  the  upper  or  under  surface  of  the  penis ;  in  the  former 
case,  the  malformation  constitutes  what  is  called  epispadias,  in 
the  latter,  hypospadias.  I  have  seen  no  example  in  which  the 
orifice  w^as  situated  at  the  side  of  the  median  line  of  the  gland. 
The  urethra  sometimes  terminates  at  the  inferior  portion  of  the 
abdomen.  Ilaller  refers  to  an  instance  in  which  it  opened  in 
the  inguinal  region ;  and  Geoftroy  Saint-llilaire  mentions  one 
where  the  meatus  was  situated  in  the  rigbt  groin. 

The  meatus,  instead  of  presenting  itself  in  the  form  of  a 
vertical  slit,  is  sometimes  of  a  rounded,  circular,  or  ovoidal 
configuration.  Its  size  may  also  be  unnatural.  Thus,  it  is 
sometimes  remarkably  large,  or  so  small  as  hardly  to  admit  the 
extremity  of  an  ordinary  silver  probe.  In  the  former  case, 
which  is  rather  rare,  it  constitutes  a  predisposition  to  gonorrhoea 
and  chancre,  from  the  fact  that  it  offers  an  unusually  wide 
surface  for  the  contact  and  lodgment  of  the  specific  virus. 

The  meatus  is  sometimes  double,  and  even  triple;  a  circum- 
stance which  has  led  to  a  belief,  at  one  time  common  enough 
among  anatomists,  of  the  existence  of  a  double  urethra.  In  the 
celebrated  case  of  Fabricius  Ilildanns,  so  often  cited  in  support 
of  this  opinion,  there  were  two  openings  on  the  head  of  the 
penis,  but  only  one  canal.  Vidal  relates  an  instance  in  which 
there  were  three  orifices,  two  of  which  pierced  the  gland,  while 


MALFORMATIONS    OF    THE    URETHRA.  555 

the  other  was  situated  at  the  lowermost  part  of  the  iiavicuhir 
fossa,  iiearlj'  at  the  base  of  the  freniim.  Tlie  latter  was  quite 
capacious,  and  afforded  vent  both  to  the  urine  and  the  semen; 
the  rest  were  very  small  and  contracted,  and  permitted  the  urine 
to  p)ass  only  when  this  fluid  was  ejected  with  unusual  force.  I 
have  met  with  several  instances  of  double  meatus,  in  none  of 
which,  however,  more  than  one  opened  into  the  urethra,  the 
other  ending  in  a  blind  pouch.  Such  a  condition  generally 
represents  the  lightest  grade  of  hypospadias,  the  normal  opening 
being  denoted  by  a  gutter  two  or  three  lines  deep. 

Tlie  orifice  is  occasionally  occluded,  either  partially  or  com- 
pletely. In  the  former  case,  the  narrowing  may  be  effected  l)y 
an  unusually  small  opening  with  inverted  edges;  in  the  latter, 
hy  an  extension  of  the  mucous  membrane,  or  of  the  mucous 
membrane  and  a  small  quantity  of  the  proper  structure  of  the 
gland. 

A  similar  arrangement  occasionall}^  exists  in  the  uretlira  of 
the  female.  A  very  rare  and  interesting  case  of  membranons 
closure  of  this  tube,  associated  with  patenc}^  of  the  urachus,  was 
observed  by  Berthelemi  Cabrol,  of  Montpellier,  in  a  girl  eighteen 
3^ears  old.  The  urine  had  escaped,  ever  since  birth,  at  the  um- 
bilicus, which  projected  about  four  inches  from  the  abdomen, 
and  exhaled  an  intolerable  stench.  A  very  similar  case  is  recorded 
by  Pith  a. 

2.  The  urethra  may  be  absent.  Of  this  occurrence  the  best 
marked  example  is  seen  in  that  variety  of  exstrophy  of  the 
bladder  in  which  the  urine  and  semen  are  discharged  above  the 
pubes.  This  species  of  malformation  is  exceedingly  rare,  and  is 
necessarily  accompanied  with  impotence.  The  canal  in  question 
is  sometimes  preternaturally  narrow,  or  completely  occluded. 
The  defect  may  involve  the  entire  canal,  or  it  may  be  limited  to 
a  particular  portion.  Jules  Cloquet  met  with  an  instance  in  a 
new-born  child,  in  which  the  contraction  existed  at  the  middle 
of  the  urethra,  and  was  upwards  of  an  inch  in  length.  Com- 
plete atresia,  without  deformity  of  the  penis,  can,  however, 
scarcely  exist,  and  a  careful  examination  will  disclose  a  very 
minute  orifice  somewhere  along  the  course  of  the  inferior  wall 
of  the  urethra,  and  behind  the  corona  of  the  gland.  ITence, 
these  cases  must  be  regarded  simply  as  examples  of  imperfora- 


556  MALFORMATIONS    OF    THE    URETHRA. 

tion  of  the  glandular  portion  of  the  canal,  with  a  light  grade  of 
hypospadias.' 

The  passage  is  occasionally  closed  by  a  prolongation  of  the 
mucous  covering  of  the  head  of  the  penis;  or  hy  an  internal 
septum,  formed  by  a  duplicature  of  the  lining  meml)rane ;  or, 
tinalh',  by  a  sort  of  fibrous  substance.  These  varieties  of  occlu- 
sion of  the  urethra  bear  the  greatest  possible  analogy  to  those  of 
the  rectum,  and  require  the  same  modes  of  treatment  for  their 
relief. 

3.  Many  authors  speak  of  what  they  regard  as  a  double  ure- 
thra; but  tlicre  is  no  instance  of  a  well  authenticated  character, 
which  tends  to  show  that  there  has  ever  been  two  distinct 
channels  for  the  transmission  of  the  urine.  The  existence  of  a 
second  canal  in  the  median  furrow  of  the  back  of  the  jijcnis  is 
due  either  to  the  displaced  openings  of  the  ejaculatory  ducts,  as 
in  the  cases  recorded  by  Vesalius,  Cruveilhier,  and  Testa,  or  to 
deviation  of  the  prostatic  ducts,  with  or  without  aberration  of 
the  anterior  commissure  of  the  gland,  to  which  reference  is  made 
at  page  439.  In  a  solitary  instance  of  apparent  double  urethra, 
the  second  passage,  seated  on  the  inferior  surface  of  the  penis 
parallel  with  the  urethra,  was  found,  by  Monod,  in  a  monstrous 
foetus,  with  imperforate  anus,  to  be  nothing  more  than  a  fecal 
fistule. 

4.  The  urethra  is  liable  to  changes  of  form.  These  seldom 
pervade  the  entire  canal,  but  are  limited  to  particular  portions 
of  its  extent.  Of  these,  the  navicular  fossa  is,  perhaps,  most 
frequently  affected.  This  part,  which  is  naturally  very  wide,  is 
sometimes  absent,  so  that  the  spongy  portion  of  the  urethra  is 
throughout  of  the  same  uniform  dimensions.  At  other  times, 
although  very  rarely,  the  fossa  is  remarkably  dilated,  or  expanded 
into  an  elongated  pouch,  which  may  thus  serve  as  a  temporary 
reservoir  for  the  urine,  the  seminal  fluid,  and  even  calculous 
concretions,  especially  when  it  happens  to  be  conjoined  with  an 
unusually  narrow  meatus.  If,  on  the  contrary,  the  meatus  is 
very  capacious,  as  when  it  extends  as  far  as  the  base  of  the  gland, 
constituting  the  first  degree  of  hypospadias,  it  may  form  a  serious 
inconvenience,  inasmuch  as  it  predisposes  the  part  to  the  venereal 

'  Vide,  Rauclifnss,  St.  Petersburger  Med.  Zeitscbr.,  Bd.  ii.,  18G2,  p.  167; 
Stilling,  Deutscbe  Kliuik,  1804,  p.  319;  and  Le  Fort,  Gaz.  Hebd.,  1864,  p.  593. 


MALFORMATIONS  OF  THE  URETHRA.        557 

infection  by  afFording  lodgment  to  gonorrhceal  and  chancrous 
matter. 

Tlie  bulbous  part  of  the  canal  is  occasionally  unnaturally 
dilated,  forming  a  species  of  cul-de-sac,  well  calculated  to  arrest 
the  point  of  the  catheter,  and  impede  its  progress  towards  the 
bladder.  In  some  cases,  very  few,  however,  in  number,  this 
part  presents  an  unusually  projecting  septum,  equally  calculated 
to  embarrass  the  operator. 

The  sinus  in  front  of  the  verumontanum  is  sometimes  so  much 
enlarged  as  to  be  capable  of  receiving  the  end  of  a  very  laro-c 
catheter ;  and  a  similar  expansion  is  occasionally  seen  at  each 
side  of  this  crest. 

In  some  instances,  the  verumontanum  is  prolonged  much 
farther  back  than  usual,  giving  rise,  hy  a  species  of  expansion, 
to  two  lateral  folds,  which  are  continuous  in  front,  and  resemble 
two  little  valves.  An  analogous  arrangement  sometimes  exists 
towards  the  membranous  portion  of  the  urethra,  but  in  this  case 
the  concave  margin  of  the  valve-like  process  looks  towards  the 
bladder  instead  of  forwards.  This  variety  of  malformation, 
which  is  probably  sometimes  the  result  of  disease,  was  first 
delineated  by  Langenbeck  in  his  memoir  on  lithotomy,  and  has 
been  particularly  noticed  by  Velpeau  in  his  Surgical  Anatomy. 
Lisfranc  states  that  he  has  several  times  seen  a  depression  be- 
tween the  two  lateral  lobes  of  the  prostate.  In  one  of  his  cases, 
the  abnormal  cavity  was  two  lines  in  length,  a  line  in  width, 
and  a  line  and  a  half  in  depth ;  the  gallinaginous  crest  was  de- 
formed, and  directed  towards  the  right  side. 

5.  The  urethra  sometimes  deviates  from  the  normal  direction. 
In  the  infant,  in  whom  the  bladder  is  elongated,  and  situated, 
in  a  great  measure,  in  the  abdominal  cavity,  the  canal  is  a  good 
deal  more  curved  than  in  the  adult.  It  is  also  influenced,  in 
some  instances,  by  the  height  and  shape  of  the  pubes.  In  the 
foetus,  according  to  Chaussier,  its  curvature  is  often  augmented 
by  the  distention  of  the  rectum  by  the  meconium. 

Cases  occur  in  which  the  canal  terminates  in  the  bladder  a 
little  lower  down  than  usual ;  a  circumstance  which  materially 
diminishes  the  bas-fond  of  the  bladder,  and  predisposes  to  incon- 
tinence of  urine.  The  prostatic  portion  of  the  urethra  occasion- 
ally runs  through  the  gland  of  that  name  in  such  a  manner  that 
nearly  the  whote  of  that  body  lies  above  it.     In  such  a  case,  the 


558  MALFORMATIOXS    OF    THE    URETHRA. 

urethra  is  in  close  contact  with  the  rectum,  which  must  thus  be 
endangered  in  the  O[)eration  for  stone.  In  some  instances  the 
reverse  of  this  is  the  case,  the  canal  being  lodged  in  a  mere 
gutter  in  the  upper  surface  of  the  gland.  I  am  not  aware  that 
any  lateral  deviations  have  been  observed;  if  any  occur,  they 
must  be  exceedingly  infrequent. 

One  of  the  most  common,  and  at  the  same  time  one  of  the 
most  serious,  effects  of  congenital  obstruction  of  the  urethra  is 
excessive  distention  of  the  l:)ladder,  with  enlargement  of  the 
ureters,  and  organic  disease  of  the  kidneys ;  consisting,  generally, 
in  cystoid  dilatation  of  their  substance.  These  alterations  also 
show,  what  has  not  been  admitted  by  all  physiologists,  that 
micturition  is  naturally  performed  before  birth,  and  that  the 
secretion  of  urine  may  be  carried  on  even  after  the  renal  tissues 
are  almost  entirely  destroyed. 

Many  of  the  defects  now  described  are,  of  course,  irremediable, 
and  are,  on  tliis  account,  more  interesting  to  the  physiologist 
and  pathologist  than  to  the  surgeon.  There  are  some  of  them, 
however,  wdiich  admit  of  relief,  and  which,  therefore,  require 
further  notice  in  this  place. 

Occlusion  of  the  external  meatus  of  the  urethra  must  be 
speedily  remedied  by  an  operation,  otherwise  the  urine  may 
accumulate  to  so  great  an  extent  as  to  lead  to  a  rupture  of  the 
canal,  with  an  infiltration  of  the  fluid  in  the  connective  tissue. 
Unfortunatelj'  the  existence  of  tliis  malformation  cannot  always 
be  at  once  determined,  on  account  of  the  narrow  and  elongated 
condition  of  the  prepuce,  which  prevents  the  inspection  of  the 
affected  part.  It  is  only,  in  general,  in  consequence  of  the 
absence  of  micturition,  and  the  presence  of  a  small,  elastic,  and 
translucent  swelling  behind  the  head  of  the  penis,  that  attention 
is  directed  to  the  seat  of  the  malformation,  and  the  proper 
means  of  overcoming  it.  When  the  occlusion  is  caused  simply 
by  a  duplicature  of  the  lining  membrane,  forming  a  sort  of 
hymen,  septum,  or  diaphragm,  a  vertical  incision  in  the  direction 
of  the  natural  outlet  will  generally  suffice  to  afford  relief;  the 
}irecaution  being  observed  to  keep  the  edges  of  the  wound  apart 
b}'  the  daily  introduction  of  the  steel  bougie.  When,  on  the 
contrary,  the  imperforation  depends  upon  the  presence  of  a 
fibrous  tissue,  and  reaches  a  considerable  distance  back,  the  ope- 
ration will  be  more  serious,  and  will  require  to  be  performed 


MALFORMATIOXS    OF    THE    UEETHRA.  559 

with  a  trocar,  the  cauula  of  which,  or  a  proper  substitute,  may 
be  employed  afterwards  to  keep  the  canal  pervious. 

In  the  extraordinary  case  observed  by  Cabrol,  where  the  occlu- 
sion was  combined  with  patency  of  the  urachus,  a  cure  was 
effected  b}^  dividing  the  abnormal  septum,  and  retaining  a 
catheter  in  the  bladder  for  conducting  off  the  urine.  The  day 
after  the  operation,  the  surgeon  threw  a  strong  ligature  around 
the  tumor  at  the  navel,  and  then  cut  oft'  the  redundant  portion, 
the  raw  surface  being  immediately  touched  with  the  actual 
cautery.  As  soon  as  the  eschar  was  detached,  the  sore  was 
dressed  with  a  healing  salve,  and  in  less  than  a  fortnight  the 
cicatrization  was  completed. 

When  the  occlusion  depends  upon  union  of  the  pudendal  lips, 
a  tedious  dissection  may  be  necessary  to  expose  the  concealed 
outlet.  The  incision  should  be  made  directly  along  the  middle 
line,  and  the  operation  may  be  finished,  if  necessary,  with  the 
trocar. 

The  malformations  known  under  the  names  of  hypospadias 
and  epispadias  are  defects  of  a  serious  character,  as  they  entail 
not  infrequently  great  suftering  and  inconvenience  upon  their 
uidiappy  subjects.  From  the  manner  in  which  the  urine  is 
discharged,  the  neighboring  parts  are  kept  continually  in  a 
tender,  irritable,  and  excoriated  state ;  at  the  same  time  that 
they  exhale  so  unpleasant  an  odor  as  to  render  the  patient  dis- 
agreeable both  to  himself  and  to  those  around  him.  But,  what 
is  worse  than  all,  they  often  render  the  individual  im[)Otent, 
and  thus  disqualify  him  for  matrimony.  This  must  necessarily 
be  the  case  whenever  the  defect  exists  far  back,  and  is  so  great 
as  to  allow  the  wdiole  of  the  semen  to  escape  at  the  preternatural 
aperture ;  or  where  the  fissure  extends  all  the  way  fiom  the  pubic 
symphysis,  or  the  perineum,  to  the  head  of  the  penis.  Examples 
of  this  description  are,  therefore,  of  the  deepest  interest  in  a 
medico-legal  point  of  view  ;  for,  although  the  subjects  of  them 
may  be  able  to  copulate,  yet,  from  their  inability  to  project  the 
semen  into  the  uterus,  the  intercourse  cannot  prove  fruitful. 
When  the  malformation  is  associated  with  shortening  and  in- 
curvation of  the  penis,  or  excessive  length  of  the  memlKU-  with 
great  redundancy  of  the  prepuce,  even  copulation  may  be  im- 
practicable. Hypospadias  and  epispadias  occasionally,  although 
rarely,  coexist. 


660  MALFORMATIONS    OF    THE    URETHRA. 

Hypospadias  presents  itself  uiifler  three  varieties  of  form,  of 
wliicli  the  most  common,  as  well  as  the  most  simple,  is  the  one 
in  which  the  urethra  opens  just  behind  the  frenura  ;  it  is  gene- 
rally accompanied  hy  a  fissure  of  the  gland,  which  is  destitute 
of  a  natural  orifice,  and  has  a  broad,  flattened,  and  unseemly 
appearance.  In  the  second  form,  the  canal  opens  at  some  point 
intermediate  between  the  first  and  the  scrotum  ;  and  in  the 
third,  the  urethra  terminates  at  the  latter  organ,  which  is  cleft 
at  the  middle  line,  so  as  to  form  two  lobes,  closely  resembling 
the  pudendal  lips.  In  the  second  variety  of  the  malformation, 
the  urethra  extends  occasionally  as  far  forwards  as  the  crown  of 
the  penis,  where  it  ends  in  a  sort  of  cul-de-sac. 

In  the  more  simple  variety  of  hyposj^adias,  a  cure  may  be  at- 
tempted by  paring  the  edges  of  the  fissure,  and  uniting  them  by 
means  of  interrupted  sutures  over  a  catheter  introduced  into  the 
bladder.  The  sutures  should  be  placed  near  each  other,  and  the 
intervals  between  them  should  be  carefully  closed  with  strips  of 
isinglass  plaster.  They  should  not  be  removed  before  the  end 
of  the  sixth  day,  by  which  time  the  greater  portion  of  the  wound 
w^ill  have  pretty  firmly  united.  Any  part  that  may  remain  un- 
closed may  be  touched  with  nitrate  of  silver,  to  induce  the  forma- 
tion of  healthy  granulations.  The  same  mode  of  proceeding  is 
adojited  when  the  fissure. exists  farther  back,  only  that  it  will 
be  necessary,  in  addition,  to  establish  an  artificial  urethra  by 
means  of  a  trocar,  pushed  in  the  direction  of  the  natural  channel. 
The  canal  thus  made  is  kept  pervious  by  the  catheter,  until  it 
has  received  a  mucous  lining,  after  which  the  instrument  should 
be  worn  a  few  hours  every  day  for  a  number  of  months,  to  pre- 
vent undue  contraction,  which  is  so  apt  to  folloAV  all  operations 
of  this  kind.  When  there  is  much  deficiency  of  the  parts,  auto- 
plasty  may  be  necessary,  the  gaj)  being  filled  up  by  borrowing 
a  piece  of  integument  from  the  scrotum  or  perineum. 

When  hypospadias  is  complicated  with  great  shortening  of  the 
spongy  substance  of  the  urethra,  accompanied  with  incurvation 
of  the  penis,  the  defect  may  sometimes 'be  remedied  by  cutting 
out  a  V-shaped  j)iece  of  the  cavernous  bodies,  at  their  dorsal 
surface.  Such  an  operation,  which  was  performed  successfully, 
many  years  ago,  by  the  late  Dr.  Physick,  and  also,  in  1841,  by 
Professor  Pancoast,  of  Philadelf)hia,  I  have  practised  several 
times  with  the  most  gratifying  results.     It  may  be  divided  into 


MALFORMATIONS  OF  THE  URETHRA. 


561 


three  stages.  In  the  first,  the  skin  of  the  dorsal  snrfaco  of  the 
penis  is  pinched  uplongitndinally<,andthen  divided  transversely 
by  transfixing  its  base.  Secondly,  the  cavernous  bodies  being 
thus  exposed,  a  wedge-shaped  piece,  from  half  an  inch  to  an  inch 
in  length,  according  to  the  extent  of  the  incurvation,  and  em- 
bracing about  two-thirds  of  the  thickness  of  the  two  cylinders, 
is  excised  with  the  bistoury,  by  carrying  the  instrument  in  a 
sloping  direction,  first  from  behind  forwards  towards  the  gland, 
and  then  backwards  towards  the  pubes.  The  hemorrhage  is 
usually  slight,  and  ceases  of  its  own  accord.  Lastlj',  the  edges 
of  the  triangular  wound  are  tacked  together  by  several  points 
of  the  interrupted  suture ;  after  which  the  penis  is  placed  in  a 
hollow,  well-padded  splint,  to  Avhich  it  is  secured  by  an  appro- 
priate roller.  Cold  water  dressings  are  applied,  to  prevent  undue 
inflammation,  and  the  stitches  are  removed  at  the  end  of  the 
fifth,  sixth,  or  eighth  day,  according  to  the  degree  of  the  re- 
union. 

In  a  case  of  hypospadias,  accompanied  with  considerable  in- 
curvation, which  was  under  my  charge  some  years  ago,  I  dis- 
sected off  the  integuments  at  the  seat 

of  the  bend,  and  then  made  four  hori- 
zontal incisions,  at  intervals  of  several 

lines,  into  the  fibrous  sheath  of  the 

cavernous  bodies,  in  order  to  restore 

them    to    their  normal  length.      The 

operation  had  the  efiiect  intended,  but, 

in    consequence   of    the    difficulty   of 

keeping    the   organ    extended,   there 

was    a    reproduction    of    the    curve 

within  a  very  short  period  after  the 

cicatrization  of  the  parts. 

In  e]:)ispadias,  which  is  far  more  rare 

than   hypospadias,   the  malformation 

aflects  the  dorsal  surface  of  the  penis, 

and     likewise    presents    itself    under 

several  varieties  of  form.     In  the  subjoined  sketch,  fig.  169, 

copied  from  Liston,  the  fissure  extends  from  the  pubic  symphysis 

to  the  extremity  of  the  penis,  which  has  a  singularly  flattene.l 

and  distorted  appearance.     The  mucous  membrane,  in  this  con. 

dition  of  the  parts,  is  generally  abnormally  pale,  and  its  lacunas 
36 


Fig.  169. 


Epispadias. 


562 


MALFORMATIONS  OF  THE  URETHRA. 


Fie;.  170. 


are  very  distinct.  In  the  more  simple  forms  of  epispadias,  the 
urethra  terminates  a  short  distance  behind  the  gland  of  the  penis, 
Avhich  is  usually  more  or  less  disfigured. 

The  treatment  for  the  rectification  of  these  defects  is  to  be 
conducted  upon  the  same  principles  as  that  for  the  difterent 
varieties  of  hypospadias,  already  described.  In  Mr.  Liston's 
case,  in  which  nearly  four  inches  of  the  urethra  were  exposed, 
a  complete  cure  was  effected  in  a  few  days.  The  operation 
consisted  in  paring  the  edges  of  the  cleft  thoroughly,  and  bring- 
ing them  together  over  a  catheter,  by  means  of  many  points  of 
the  twisted  suture.  Union  by  the  first  intention  took  place  in 
the  entire  track,  except  near  the  pubes,  where  a  very  minute 
fistulous  opening  remained,  through  which  not  more  than  a  drop 
of  urine  oozed  during  micturition.  This  was  afterwards  closed 
with  a  heated  needle.  The  organ  was  in  all  respects,  and  for  all 
purposes,  as  perfect  as  could  be  desired. 

A  far  better  procedure  for  closing  in  the  urethra  is  that  of 
Xelaton,  which  has  been  variously  modified  by  other  surgeons. 

This  consists  in  making  a  longi- 
tudinal incision  o]i  each  side,  at 
the  junction  of  the  skin  and 
mucous  membrane,  and  refresh- 
ing the  edges  so  as  to  make  raw 
surfaces,  nearly  an  eighth  of  an 
inch  in  width,  to  which  are  at- 
tached the  sides  of  a  flap  turned 
down  from  the  hypogastric  re- 
gion. To  maintain  this  flap  in 
position  and  prevent  its  retrac- 
tion during  the  cicatrization  of 
the  abdominal  wound,  it  is 
covered  by  a  crescentic  flap 
taken  from  the  scrotum, 
through  which  the  penis  is 
slipped,  so  that  its  raw  surface  lies  in  contact  with  the  raw 
surface  of  the  first  flap,  to  which  it  is  fastened  by  twisted 
sutures,  as  represented  in  fig.  170,  from  Eichard.  AVhatever 
operation  may  be  selected,  it  is  important  to  make  a  perineal 
outlet  for  the  urine,  through  which  its  contact  with  the  edges 
of  the  wound  may  be  prevented. 


Nelaton's  Operation  for  Epispadias. 


CHAPTER    XIV. 

LESIONS  OF  THE  GALLINAGINOUS  CREST. 

The  gallinaginous  crest,  or,  as  it  is  denominated,  the  veru- 
montanum,  is  liable,  from  its  situation  at  the  floor  of  the  pros- 
tatic portion  of  the  urethra,  and  from  its  intimate  relation  to 
the  orifices  of  the  ejaculatory  and  prostatic  ducts,  to  inflamma- 
tion and  its  consequences.  Whether  these  aftections  ever  exist 
as  independent  afl:ections,  or  whether  they  always  occur  in 
association  with  disease  of  the  neighboring  structures,  is  not 
clearly  ascertained. 

Acute  inflammation  of  the  gallinaginous  crest  is  most  com- 
monly induced  by  an  extension  of  gonorrhoea!  inflammation,  by 
stricture  of  the  urethra,  by  disease  of  the  ejaculatory  ducts,  and 
by  the  presence  of  prostatic  calculi.  It  may  also  be  excited, 
there  is  reason  to  believe,  by  rough  hoi-seback  exercise,  by  inor- 
dinate sexual  indulgence,  and  by  the  injudicious  employment  of 
instruments.  Stimulating  diuretics,  such  as  cantharides  and 
spirit  of  turpentine,  may  also  give  rise  to  it.  Tlie  crest,  when 
thus  affected,  is  of  a  florid  appearance,  of  a  soft,  spongy  consis- 
tence, and  slightly  increased  in  volume,  in  consequence  of  inter- 
stitial deposits.  Inflammatory  new  material  is  sometimes  depo- 
sited on  its  surface,  either  in  the  form  of  minute  points,  or  as  a 
distinct  layer. 

There  are  no  signs  by  wdiicli,  in  the  present  state  of  the  science, 
it  is  possible  to  diagnosticate  this  affection  from  disease  of  the 
adjacent  parts.  The  spasm,  pain,  and  frequent  desire  to  urinate,. 
together  with  the  increased  secretion  of  mucus  which  accompany 
it,  also  attend  inflammation  of  the  prostate  gland  and  the  neck 
of  the  bladder,  and  are,  therefore,  valueless  as  diagnostics.  The 
circumstance  is,  fortunately,  of  little  moment  in  a  practical  point 
of  view,  inasmuch  as  the  treatment  is  essentially  the  same,  in 
whichever  of  these  structures  the  malady  is  located.  Under 
the  influence  of  antiphlogistics,  the  lesion  rapidly  subsides,  and 
the   i:)art  gradually    recovere   its  original    character.     Neither 


564  LESIONS    OF    THE    G ALLINAGINOUS    CREST. 

ulceration  nor  gangrene  is  likely  to  occur,  unless  the  inflam- 
mation has  been  induced  by  external  violence,  attended  with 
extensive  laceration  of  its  tissues. 

The  gallinaginous  crest  is  liable  to  hypertrophy,  or  chronic 
enlargement;  the  result,  doubtless,  of  inflammation  and  inter- 
stitial deposits.  In  stricture  of  the  urethra  and  hypertrophy  of 
the  prostate,  I  have  repeatedly  seen  it  from  three  to  four  times 
the  normal  volume,  at  the  same  time  that  it  was  considerably 
indurated,  and  changed  in  its  configuration.  Occasionally,  it 
deviates  a  good  deal  to  one  side.  The  size  which  this  body  some- 
times attains  is  almost  incredible.  Thus,  in  an  instance  recorded 
by  De  Blegny,  it  formed  a  projection  as  big  as  a  small  walnut. 
The  seminal  fluid  was  of  a  thick,  vitiated  quality,  and  the  ejac- 
ulatory  canals  were  choked  up  with  small,  hard,  spherical  con- 
cretions, as  large  as  peas.  The  patient,  a  widower,  sixty  years 
of  age,  and  the  father  of  several  children,  contracted  a  second 
marriage,  but  he  never  could  produce  an  emission,  although  he 
'  liad  perfect  erections.  In  an  old  man  who  died  of  retention  of 
urine  at  the  Hotel-Dieu,  in  Paris,  the  verumontanum  was  still 
larger  than  in  the  case  of  De  Blegny.  The  hypertrophy  was  asso- 
ciated with  profound  disease  of  some  of  the  other  portions  of  the 
urinary  passages,  and  it  was,  therefore,  impossible  to  ascertain 
the  amount  of  influence  it  exercised  during  the  patient's  life.' 

AVhen  the  verumontanum  is  much  enlarged,  it  is  generally  of 
a  pale,  mottled  complexion,  more  or  less  deformed,  and  consider- 
ably augmented  in  its  consistence.  Its  mucous  membrane  is 
thickened,  villous,  and  traversed  by  large  vessels ;  while  its 
proper  substance  is  of  a  whitish,  or  grayish  aspect,  intersected 
l)y  fibrous  bands,  and  so  firm  as  almost  to  grate  under  the  knife. 
Hypertro[,thy  of  this  bodj",  existing  in  any  considerable  degree, 
must  necessarily  obstruct  the  flow  of  urine,  and  interfere  with 
the  introduction  of  the  catheter.  In  this  respect,  in  fact,  its 
ett'ects  must  be  similar  to  those  produced  by  hypertrophy  of  the 
prostate,  especially  of  its  middle  lobe.  From  its  intimate  rela- 
tions with  the  ejaculatory  ducts,  it  must  also  impede,  if  not 
wholly  prevent,  the  discharge  of  semen,  and  may  thus  become 
a  cause  of  impotence.     This  was  evidently  the  case  in  the  iudi- 

'  Civiale.  Traite  Pratique  deS" Maladies  des  Organes  Genito-Urinaires,  deux, 
•ed, ,  partie  2de,  p.  234. 


LESIONS    OF    THE    G  ALLINAGINOUS    CREST.  565 

viclual  whose  history  lias  been  narrated  by  De  Bl^gii}^,  and  which 
is  alluded  to  in  a  previous  paragraph.  Sir  Everard  Home  met 
with  an  instance  in  Avliich  the  orifices  of  the  ejaculatory  ducts 
were  covered  over  by  a  false  membrane. 

Hypertrophy  of  the  urethral  crest  has  no  symptoms  of  its  own, 
and  hence  the  utmost  uncertainty  must  always  exist  with  regard 
to  its  diagnosis.  The  phenomena  Avhich  attend  it  must  be  such, 
in  the  great  majority  of  instances,  as  indicate  obstruction  to  the 
•flow  of  urine,  and  the  passage  of  instruments  accompanied,  in 
all  probability,  by  an  increased  discharge  of  glairy,  viscid  mucus. 
A  careful  exploration  with  the  sound,  aided  by  the  finger  in  the 
rectum,  may  throw  some  light  upon  the  case,  bj^  pointing  out 
the  precise  seat  of  the  enlarged  body ;  but,  in  general,  even  this 
fails,  and  the  practitioner  is,  therefore,  obliged  to  abandon  him- 
self wholly  to  conjecture.  This  being  the  case,  it  is  obvious 
that  the  treatment  of  the  affection  must  be  conducted  accord- 
ing to  the  common  rules  of  surgery ;  or,  more  properly  speak- 
ing, upon  the  same  principles  as  chronic  disease  of  the  prostate 
gland,  the  neck  of  the  bladder,  and  the  j)Osterior  portion  of  the 
urethra. 


INDEX. 


ABSCESS  of  bla.]cler,  29 
causes  of,  30 
diagnosis  of,  31 
prognosis  of,  81 
symptoms  of,  31 
treatment  of,  32 
of  prostate,  376 

direction  in    which  it  may  dis- 
charge, 377 
symptoms  of,  378 
treatment  of,  379 
urinary,  511 

causes  of,  512 
diagnosis  of,  514 
site  of,  511 
symptoms  of,  513 
treatment  of,  515 
Absence  of  bladder,  355 

urethra,  555 
Animoninco-magnesian  calculus,  183 
Arterial  compressor  for  lithotomy,  260 
Aspirator,  133 
Aspiration  of  bladder,  133 
Atony  of  bladder,  85.     See  Paralysis. 
Atrophy  of  bladder,  328 
prostate,  412 


BAR  at  neck  of  bladder,  69 
between  the  ureters,  58 
Bilateral  lithotomy,  285 
Bilobed  bladder,  257 
Bistouri-cach6,  480 
Buchanan's  staff,  201 
Bladder,  abscess  of,  29 

absence  of,  355 

aspiration  of,  133 

atony  of,  85 

bilobed,  357 

carcinomatous  tumors  of,  142 

catarrh  of,  43 

croupous  inflammation  of,  27 

diseases  of,  17 

epithelioma  of,  142 

exstrophy  of,  358 

faradization  of,  97 

fibrous  tumors  of,  135 

fistule  of,  326 


Bladder — 

foreign  bodies  in,  305 

functional  diseases  of,  68 

gangrene  of,  32 

hemorrhage  of,  158 

hernia  of,  343 

hypertrophy  of,  65 

imperfections  of,  355 

inflammation  of,  acute,  17 
chronic,  43 
croupous,  27 

inversion  of,  349 

irritability  of,  68 

malformations  of.  355 

malpositions  of,  343 

neuralgia  of,  80 

papillary  fibroma  of,  136 

paralysis  of,  85 

polyp  of,  140 

polypoid  fibroma  of,  140 

puncture  of,  129 

rupture  of,  316 

sacculation  of,  62 

sarcomatous  tumors  of,  146 

spasm  of,  78 

stammering  of,  57,  121 

stone  in,  lij4 

suppuration  of,  29 

tubercle  of,  155 

tumors  of,  135 

ulceration  of,  35 

varix  of,  156 

villous  growth  of,  136 

washing  out  the,  51 

wounds  of,  309 
Bougie,  exploratory  bulbous,  463 

filiform,  476 
Bougies,  gum-elastic,  474 
Button-hole  operation  for  stricture,  48/ 


C 


ALCULI,   extraction   of  through   ure- 
thra, 222 
urinary.      See  Stone  in  the  Bladder, 
of  the  prostate,  426 
effects  of,  429 
symptoms  of,  430 
treatment  of,  432 


568 


INDEX. 


Calculi  — 

of  the  urethra,  53" 
treatment  of,  539 

by  excision,  543 
by  extraction,  540 
by  lithotiity,  542 
Carbonate  of  lime  calculus,  184 
Carcinomatous  tumors  of  the  bladder,  142 
of  the  prostate,  41 G 
excision  of,  420 
Caruncle  of  urethra,  531 
Catarrh  of  the  bladder,  43 
causes  of,  43 
cauterization  in,  53 
cl)aracter  of  mucus  in,  45 

urine  in,  45 
cystotomy  for,  54 
pathology  of,  ^7 
prognosis  of,  47 
symptoms  of,  46 
treatment  of,  48 
washing  out  bladder  for,  51 
Catheterism,  121 
in  female,  127 
obstacles  to,  125 
Catheters,  122 

bloo.l,  116  ' 

extraction  of,  129 
flexible,  114 
French,  114 
Gouley's  t'innelled.  111 
Gross's  prostatic,  115 
Holt's  winged,  127 
intraction  of,  129 
introduction  of,  124 
Merciei's  prostatic,  114 
mode  of  securing,  126 
silver,  122 
Catheter  scale,  474 

Cauterization  in  catarrh  of  bladder,  53 
irritability  of  bladder,  78 
morbid  sensibility  of  urethra,  445 
Colpocystotomy  for  catarrh  of  bladder,  54 

ulceration  of  bladder,  42 
Concretions  of  prostate,  426 
Congenital  occlusion  of  urethra,  555 
Contused  wounds  of  bladder,  309 
Croupous  inflammation  of  bladder,  27 

treatment  of.  29 
Cyst,  urinary,  from  stricture,  465 
Cystic  oxide  calculus,  182 
tumors  of  prostate,  413 

retention  of  urine  from,  418 
Cystitis,  acute,  18 

causes  of,  18 
pathology  of,  18 
prognosis  of,  22 
symptoms  of,  19 
treatment  of,  22 
chronic.     See  Catarrh  of  Bladder, 
after  lithotomy,  265 
Cystocele.     See  Hernia  of  Bladder,  343 


Cyetorrhoea.      See  Catarrh  of  Bladder,  43 
Cystotomy  for  catarrh  of  bladder,  54 

rupture  of  bladder,  323 

ulceration  of  bladdei',  42 


DILATATION  of  stricture,  473 
continuous,  477 

temporary,  475 
Diseases  of  the  bladder,  17 

prostate  gland,  371 

urethra,  441 

urinary  organs,  17 
Divulsion  of  stricture,  477 
Divulsor,  Richardson's,  477 
Double  urethra,  556 


ECTOPIA  of  the  ducts  of  the  prostate, 
439 
Elytrorraphy,  347 

Encephaloid   carcinoma   of   the    bladder, 
143 
prostate,  416 
sarcoma  of  bladder,  147 
prostate,  421 
Enuresis,  98 
Epispadias,  561 

treatment  of,  562 
Epithelioma  of  bladder,  142 

prostate,  416 
Ergot  in  hypertrophy  of  the  prostate,  409 
Errors  of  sounding,  203 
Evei'sion    of    bladder    in    vesico-vaginal 

iistule,  327 
Exploratory  bulbous  bougie.  463 
Exstrophy  of  the  bladder,  358 
Holmes's  operation  for,  364 
Levis's  operation  for,  364 
Maury's  operation  for,  366 
Wood's  operation  for,  365 
External  perineal  urethotomy,  484 
upon  a  guide,  484 
without  a  guide,  487 
Extrapelvic  lithotomy,  296 


FALSE  passages  of  urethra,  499 
causes  of,  499.  501 

diagnosis  of,  503 

effects  of,  503 

length  of,  500 

modes  of  avoiding.  476 

symptoms  of,  503 

treatment  of,  504 

varieties  in  form  of,  500 
Faradization  of  bladder,  97 
Female,  catheterism  in,  127 

lithotomy  in,  302 

lithotrity  in,  301 

staff,  302 

bladder,  stone  in,  299 


INDEX. 


569 


Female — 

stricture  of  urethra  in,  488 
urethra,    prolaps^e   of   mucous  mem- 
brane of,  526 
papillary  tumors  of,  530 
vascular  tumors  of,  5ol 
polypoid  fibroma  of,  530 
Fever,  urethral,  489 
Fibrinous  calculus,  185 
Fibromyomiitous     tumors     of     prostate, 

414 
Fibrous  tumors  of  bladder,  135 

urethra.  528 
Fistule  of   bladder.       See  Vesico-vaginal 
and  Vesico-rectal  Fistules. 
of  the  urethra,  516 
causes  of,  518 
diagnosis  of,  510 
escharotics  in,  521 
excision  of,  523 
external  incision  in,  522 
number  of  openings,  516 
prognosis  of,  520 
site  of,  510 
suture  in,  522 
treatment  of,  520 
urethroplasty  in,  523 
Fistule,  perineal,  after  lithotomy,  271 
Forceps,  crushing.  255 
lithotomy,  247 
Physick's,  250 
Foreign  bodies  in  the  bladder,  305 
effects  of,  305 
extraction  of,  306 
in  urethra,  536 

symptoms  of,  588 
treatment  of,  539 

by  excision,  543 
by  extraction,  540 
by  lithotrity,  542 
Fracture  of  calculi,  spontaneous,  214 
Functional  disorders  of  bladder,  68 

disorders  of  urethra,  441 
Fusible  calculus,  184 


GALLINAGINOUS    crest,    hypertrophy 
of,  564 
inflammation  of,  563 
lesions  of,  563 
Gangrene  of  bladder,  32 
causes  of,  32 
e9"ects  of,  34 
pathology  of,  33 
prognosis  of,  34 
treatment  of,  35 


Hematuria,  158 
Hemorrhage  after  lithotomy,  256 
Hemorrhage  of  bladder,  158 
causes  of,  158 


Hemorrhage  of  bladder — 

diagnosis  of.  160 

endemic,  159 

idiopatliic,  158 

traumatic,  158 

treatment  of,  163 
of  prostate,  434 

treatment  of,  43") 
of  urethra,  495 

spontaneous,  495 

traumatic,  495 

treatment  of,  49G 
Hemp-seed  calculus,  182 
Hernia  of  bladder,  343 
treatment  of,  345 
Hypertesthesia  of  urethra,  441 
Hypertrophy  of  bladder,  55 

symptoms  of,  59 

treatment  of,  60 
of  prostate,  392 

causes  of,  397 

effects  of.  403 

iodine  injections  in,  410 

pathology  of,  318 

symptoms  of,  399 

treatment  of,  407 

use  of  ergot  in,  409 
Hypertrophy  of  gallinaginous  crest,  564 
Hypospadias,  560 

treatment  of,  500 

piPERFECTIONS  of  bladder,  355 
JL     Impotence  after  lithotomy,  271 
Incised  wounds  of  bladder,  309 

prostate,  436 
Incontinence  of  urine,  98 

causes  of,  98 

from  external  injury,  98 

from  liyperiBSthesia,  99 

from  inflammation,  99 

from  paralysis  of  bladder.  99 

from  prostatic  changes,  103 

nocturnal,  100 

period'cal,  103 

after  lithotomy,  263 
Infiltration  of  urine,  505 

treatment  of,  509 

causes  of,  506 

diagnosis  of,  507 

prognosis  of,  508 

symptoms  of,  505 
Inflammatory  cedenia  of  scrotum,  508 
Injurious  effects  of  operations  on  urellira, 

489 
Infrapubic  function  of  bladder,  133 
Interureteral  bar,  58 
Inversion  of  bladder,  349 

complete,  351 

incomplete,  350 

symptoms  of,  353 

treatment  of,  353 


570 


INDEX. 


Iodine  injections  in  hypertrophy  of  pros- 
tate, 410 
Irritability  of  bladder,  08 

causes  of,  70 

pathology  of,  75 

prognosis  of,  70 

symptoms  of,  09 

treatment  of,  77 
Ischuria  after  lithotomy,  208 


TT'IDNEY,  surgical,  493 


LACERATED  wounds  of  bladder,  311 
prostate,  430 
urethra,  540 
Laceration  of  urethra,  54G 
causes  of,  540 
diagnosis  of,  549 
prognosis  of,  550 
symptoms  of,  647 
treatment  of,  551 
Lateral  lithotomy.     See  infra. 
Lithic  acid  calculus,  180 
Litholysis,  221 
Lithotome  cache,  286 
Lithotomy,  238 

general  results  of  different  operations 

of,  298 
bilateral,  285 

modifications  of,  287 
statistics  of,  288 
extrapelvic,  296 
lateral,  239 

accidents  in,  256 
after-treatment  of,  272 
cystitis  after,  205 
difficulties    of    extracting  stone 

in,  251 
extent  of   external   incision    in, 

251 
extraction  of  calculus  in,  246 
hemorrhage  after,  250 
impotence  after,  271 
in  children,  249 
incontinence  of  urine  after,  270 
incision  of  prostate  in,  249 
ischuria  after,  208 
lesion  of  prostate  in,  205 
mode  of  performing,  240 
mortality  after,  275 
orchitis  after,  272 
pelvic  cellulitis  after,  262 
perineal  fistule  after,  271 
peritonitis  after,  207 
phlebitis  after,  204 
pyemia  after,  207 
relapse  after,  280 
repetition  of,  284 
retention  of  urine  after,  202 


Lithotomy,  lateral — 

sinking  after,  202 

sloughing  of  rectum  after,  270 

statistics  of,  275 

sterility  after,  271 

tetanus  after,  208 

urinary  infiltration  after,  263 

use  of  scoop  in,  248 

wound  of  rectum  in,  269 
median,  288 

modifications  of,  290 

statistics  of,  290 
medio-lateral,  290 

rectangular  staff  for,  291 
recto-vesical,  291 

statistics  of,  293 
suprapubic,  293 

statistics  of,  296 
Lithotrites,  225 
Lithotrity,  224 

accidents  in,  233 
after-treatment  of,  232 
compared  with  lithotomy,  236 
conditions  favorable  to,  226 
contraindications  to,  226 
ill  effects  of,  233 
in  the  female,  301 
instruments  for,  225 
mode  of  performing,  228 
preparatory  treatment  of,  228 
relapse  after,  237 
selection  of  cases  for,  226 
statistics  of,  236 
washing  out  bladder  after,  232 
for  urethral  calculi,  542 
Lithotrity,  perineal,  236 


Malformations  of  bladder,  355 
prostate,  439 

uretlira,  554 

urinary  meatus,  554 

verumontanum,  557 
Malpositions  of  bladder,  343 

prostate,  439 
Meatus,  urinary,  double,  654 

malformations  of,  554 

occlusion  of,  555 
Median  lithotomy,  288 
ISIedio- lateral  lithotomy,  290 
Morbid  sensibility  of  the  urethra,  441 

causes  of,  441 

symptoms  of,  442 

treatment  of,  444 
INIucous  membrane  of  urethra,  prolapse  of, 

520 
Mulberry  calculus,  181 


Neck  of  bladder,  bar  at,  59 
cauterization  of,  78 
Neuralgia  of  bladder,  80 


INDEX. 


571 


Neuralgia  of  bladder — 
causes  of,  82 
diagnosis  of,  82 
symptoms  of,  81 
treatment  of,  84 
urethra,  446 

treatment  of,  448 


Occlusion,  congenital,  of  urinary  meatus, 
555 
Orchitis  after  lithotomy,  272 
Oxalate  of  lime  calculus,  181 


Papillary  fibroma  of  bladder,  136 
urethra,  530 
Paralysis  of  bladder,  85 

from  overdistention,  87 

general  causes  of,  88 

local  causes  of,  85 

prognosis  of,  92 

retention  of  urine  from,  91 

senile,  80 

symptoms  of,  01 

treatment  of,  93 
Patent  urachus,  3(38 
Pelvic  cellulitis  after  lithotomy,  262 
Perineal  fistule  after  lithomy,  271 
Perineal  section  for  stricture,  487 
Perineum,  tapping  urethra  in.  111 
Peritonitis  after  lithotomy,  267 
Phlebitis  after  lithotomy,  264 
Phosphatic  calculus,  183 
Physick's  forceps,  258 
Polyp  of  bladder,  140 
Polypoid  fibroma  of  bladder,  140 

urethra,  528 
Porte-caustique,  470 
Prostate,  abscess  of,  376 

atrophy  of,  412 

calculi  of,  426 

carcinomatous  tumors  of,  416 

concretions  on,  426 

cystic  tumors  of,  413 

diseases  of,  371 

ectopia  of  ducts  of.  439 

fibromyomatous  tumors  of,  414 

hemorrhage  of,  434 

hypertrophy  of,  392 

incision  of,  in  lithotomy,  242 

inflammation  of.  372 

lesion  of,  in  lithotomy,  205 

malformations  of,  439 

sarcomatous  tumors  of,  421 

tubercle  of,  424 

tumors  of,  413 

ulceration  of,  381 

wounds  of,  436 
Prostatitis,  acute,  372 

causes  of,  372 

diagnosis  of,  374 


Prostatitis,  acute  — 

pathology  of,  372 

symptoms  of,  372 

treatment  of,  375 
Prostatorrhoea,  384 

causes  of,  385 

diagnosis  of,  380 

pathology  of,  387 

prognosis  of,  387 

symptoms  of,  385 

treatment  of,  389 
Prolapse  of  mucous  membrane  of  urethra, 

526 
Puncture  of  bladder,  129 

infrapubic,  133 

rectal,  130 

suprapubic,  131 

through  the  symphysis,  133 
Punctured  wounds  of  bladder,  310 
Pyemia  after  lithotomy,  267 

operations  on  urethra,  492 


Rectal  puncture  of  bladder,  130 
Rectangular  staff,  291 
Recto-vesical  lithotomy,  201 
Rectum,  sloughing  of,  after  lithotomy,  270 

wound  of,  in  lithotomy,  209 
Retention  of  urine,  10 j 
after  lithotomy,  202 
causes  of,  109 
diagnosis  of,  106 
from  cystic  tumors  of  the  pros- 
tate, 413 
from  deficient  volition,  120 
from  distention  of  rectum,  119 
from  hysteria,  120 
from  inflammation,  117 
from  mechanical  obstruction,  109 
from  miasm,  121 
from  paralysis,  110 
froTU  pelvic  tumors,  117 
from  spasms,  117 
from  stricture.  111 
treatment  of,  109 
Rigors  after  operations  on  urethra,  489 

prevention  of,  491 
Rupture  of  bladder,  310 
causes  of,  316 
cystotomy  for,  323 
prognosis  of,  321 
symptoms  of.  31 8 
treatment  of,  323 
of  urethra  for  stricture,  477 


SARCOMATOUS  tumors  of  bladder,  146 
prostate.  421 
Sacculation  of  bladder,  02 
causes  of,  ()5 
prognosis  of,  66 
symptoms  of,  65 


572 


IXDEX. 


Siicculation  of  blnrliler — 

treatment  of,  07 
Scoop,  use  of  ill  lithotomy.  248 
Scrotum,  inflummatory  oedema  of,  508 

urinary  infiltration  of,  5(J7 
Shot  wounds  ot  bladder,  310 
prostate,  4.^7 
urethra,  SoO 
Sinking;  after  lithotomy,  262 
Sloughing    of    rectum    after    lithotomy, 

270 
Soundings,  dangers  of,  202 
errors  in,  203 
operation  of,  198 
Sounds,  197 
Spasm  nf  bladder,  78 
causes  of,  79 
symptoms  of,  78 
treatment  of,  79 
S[)asm  of  urethra,  449 
Spontaneous    fracture    of    st(>ne     in     the 

bladder,  214 
Staff,  female,  302 
male,  243 
rectangular,  291 
Stammering  of  bladder,  HI.  121 
Sterility  after  lithotomy.  271 
Stone  in  the  bladder,  165 
age  most  liable  to,  Ifio 
accidents  after  or  during  removal  of, 

256 
adherent,  187 
causes  of,  165 

chemical  constitution   of,  179 
ammoniaco-magnesian,   183 
carbonate  of  lime,  184 
cystic  oxide,  182 
fibrinous,  185 
fusible,  184 
lithic  acid,  180 
oxalate   of  lime,  181 
pliosphatic,  1S3 
uric  acid,  180 
urate  of  ammonia,  181 
urostealith,  185 
xanthic  oxide,  183 
color  of,  176 
consistence  of,  175 
crushing  for.     See  Lithotrity. 
diagnosis  of,  197 
encysted,   190 

extraction  of  through  urethra,  222 
forms  of,  170 
hereditary  tiature  of,  167 
in  females,  299 
in  the  negro,  l<i7 
influence  of  climate  on,  108 

race  on,  107 
medical  treatment  of,  217 
nature  of,  105 
nucleus  of,  171 


Stone  in  the  bladder — 

number  of,  173 

operations  for.    See  Lithotrity,  Litho- 
tomy, etc. 

pathological  effects  of,  212 

physical  properties  of,  171 

physical  signs  of,  197 

prognosis  of,  215 

resul  ts  of  different  operations  fur,  298 

sacculated,   188 

situation  of,  187 

solution  of,  221 

sounding  for,  197 

spontaneous  fracture  of,  214 

symptoms  of,  191 

topography  of,  167 

treatment  of,  217 

volume  of,  173 

weight  of,  174 

in  female,  298 

treatment  of,  300 

by  dilatation  of  the  urethra,  300 
by  lithotrity,  301 
by  lithotomy,  302 
Stricture  of  urethra,  451 

annular,  455 

briille,  455 

causes  of,  451 

consistence  of,  457 

diagnosis  of,  462 

effects  of,  463 

forms  of,  455 

impermeable,  456 

indurated  annular,  455 

linear,  455 

number  of,  454 

pathology  of,  452 

preparatory  treatment  of,  470 

prognosis  of,  469 

seat  of,  453 

sj'mptoms  of,  457 

treatment  of,  470 

by  dilatation,  473 
by  external  incision,  484 
by  internal  incision,  480 
by  rupture,  477 

in  the  female,  488 
Subcutaneous  urethrotomy,  485 
Suppuration  of  bladder,  29 

causes  of,  30 

diagnosis  of,  31 

prognosis  of,  31 

symptoms  of,  31 

treatment  of.  32 
Supra-pubic  lithotomj',  293 

puncture  of  bladder,  131 
Syme's  operation  for  stricture  of  urethra, 
484 

staff,  484 
Symphysis   pubis,    puncture    of    bladder 
through  the,  133 


INDEX. 


573 


TAPPING  urethra  in  perineum,  111 
Tetanus  alter  lithotomy,  268 
Tumors  of  bladder,  135 

carcinomatous,  142 
fibrous,  135 
sarcomatous,  146 
treatment  of,  148 
prostate,  413 

carcinomatous,  416 
cjstic,  413 
tibromyomatous,  414 
sarcomatous,  421 
urethra,  528 

fibrous,  528 
papillary,  530 
vascular,  531 
Tubercle  of  bladder,  155 
prostate,  424 
urethra,  528 
Tuberous  fibroma  of  bladder,  135 


ULCERATION  of  bladder,  35 
causes  of,  36 

cystotomy  in,  42 

diagnosis  of,  37 

effects  of,  38 

pathology  of,  39 

symptoms  of,  36 

treatment  of,  40 
of  prostate,  381 

symptoms  of,  382 

t)-eatment  of,  382 
Urachus,  patent,  368 
Urate  of  ammonia  calculus.  181 
Ureters,  termination  of  in  rectum,  355 

vagina.  355 
Urethra,  528 

absence  of,  555 

changes  in  form  of,  556 

congenital  obstruction  of,  559 

deviation  of,  557 

dilatation  of,  behind  stricture,  464 

diseases  of,  431 

double,  556 

extraction  of  calculi  through  the,  222 

false  passages  of,  476,  499 

fibrous  tumors  of,  528 

fistule  of,  516 

foreign  bodies  in,  536 

hemorrhage  of,  495 

hypertesthesia  of.  441 

injurious  eff'ects  of  operations  on,  489 

Laceration  of,  546 

malformations  of,  554 

morbid  sensibility  of,  441 

neuralgia  of,  446 

papillary  fibroma,  530 

polypoid  fibroma,  528 

protrusion  of  mucous  membranes  of, 

526 
spasm  of,  449 


Urethra — 

stricture  of,  451 
in  female,  488 

tapping  of  in  perineum.  111 

tumors  of,  528 
fibrous,  628 
papillary,  530 
vascular,  531 

wounds  of,  546 
Urethral  fever,  489 

preveution  of,  491 

treatment  of,  491 
Urethrometer,  472 
Urethroplasty,  523 
Urethrotomes,  481 
Urethrotomy,  external  on  a  guide,  484 

Gouley's  staff  for,  486 

results  of,  484 

subcutaneous,  485 

Syme's  staff  for,  484 

external,  without  a  guide,  487 
results  of,  488 

internal,  480 
Urethro-vaginal  fistule,  337 
Urethro-rectal  fistule,  339 
Uric  acid  calculus,  180 
Urinal  for  exstrophy  of  bladder,  367 

incontinence  of  urine,  104 
Urinary  abscess,  511 

meatus,  malformations  of,  554 

organs,  diseases  of,  17 
Urine,  character  of  in  catarrh  of  bladder, 
45 

incontinence  of,  98 

infiltration  of,  505 

after  lithotomy,  263 

retention  of,  104 
Urostealith  calculus,  185 


^'ARIX  of  bladder,  156 
urethra,  530 
Vascular  tumors  of  urethra,  531 

diagnosis  of,  532 

treatment  of,  534 
Verumuntanum,  lesions  of,  563 

malformations  of,  557 
Vesico-rect.al  fistule,  339 
Vesico-uterine  fistule,  337 
Vesico-v.'iginal  fistule,  326 

causes  of,  326 

diagnosis  of,  329 

effects  of,  328 

prognosis  of,  329 

treatment  of,  329 
Vesico-vagino-rectal  fistule.  341 
Villous  tumor  of  bladder,  136 


W 


OUNDS  of  bladder,  309 
contused  309 
incised,  309 


574 


INDEX. 


Wounds  of  bladder — 
lacerated,  310 
punctured,  310 
shot,  310 
symptoms  of,  313 
treatment  of,  314 
prostate,  43(3 
incised,  436 


Wounds  of  prostate — 
lacerated,  436 
shot,  437 
rectum  in  lithotomy,  269 
urethra,  546 


YANTHIC  oxide  calculus,  183 


SURGICAL  TEXT-BOOKS. 


A  SYSTEM  OF  SURGERY:  Pathological,  Diagnostic,  Therapeutic, 

and  Operative.  By  Samuel  D.  Gross,  M.D.,  Professor  of  Surgery  in  the  Jefferson 
Medical  College,  of  Philadelphia.  Illustrated  by  upwards  of  fourteen  hundred 
engravings.  Fifth  Edition,  carefully  revised  and  improved.  In  two  large  and 
beautifully  printed  imperial  octavo  volumes  of  about  2300  pages,  strongly  bound 
in  leather,  with  raised  bands,  $15. 

THE  SCIENCE  AND  ART  OF  SURGERY:  being  a  Treatise  on 

Surgical  Injuries,  Diseases,  and  Operations.  By  John  E.  Erichsen,  Professor  of 
Surgery  in  University  College,  London,  etc.  Revised  by  the  author  from  the  Sixth 
and  enlarged  English  Edition.  Illustrated  by  over  seven  hundred  engravings  on 
wood.  In  two  large  and  beautiful  octavo  volumes  of  over  1700  pages.  Cloth,  $9.00  ; 
leather,  $11.00. 

SURGERY:    its  Principles   and  Practice.     By  Timothy   Holmes, 

M.D.,  Surgeon  to  St.  George's  Hospital,  London.  In  one  large  and  handsome  octavo 
volume  of  nearly  1000  pages,  with  411  illustrations  on  wood.  Cloth,  $6.00 ;  leather, 
$7.00. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.    By  John 

AsHHURST,  Jr.,  M.D.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia.  In  one  very 
large  and  handsome  octavo  volume  of  about  1000  pages,  with  nearly  550  illustrations. 
Cloth,  $6.50;  leather,  raised  bands,  $7.50. 

THE  PRACTICE  OF  SURGERY.    By  Thomas  Bryant,  F.R.C.S., 

Surgeon  to  Guy's  Hospital.  With  over  five  hundred  engravings  on  wood.  In  one 
large  and  very  handsome  octavo  volume  of  nearly  1000  pages.  Cloth,  $6.25;  leather, 
raised  bands,  $7.25. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SUR- 
GERY. By  Robert  Druitt,  M.R.C.S.,  etc.  From  the  Eighth  enlarged  and  im- 
proved London  Edition.  Illustrated  with  four  hundred  and  thirty  two  wood  engra- 
vings. In  one  very  handsome  octavo  volume  of  nearly  700  large  and  closely  printed 
pages.     Cloth,  $4.00;  leather,  $5.00. 

SARGENT  ON  BANDAGING  AND  OTHER  OPERATIONS  OF 

MINOR  SURGERY.  In  one  12mo.  volume  of  383  pages,  with  one  hundred  and 
eighty-four  illustrations.     Cloth,  $1.75. 

A  PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLO- 
CATIONS. By  Frank  H.  Hamilton,  M.D.,  Surgeon  to  Bellevue  Hospital,  New 
York.  Fifth  Edition,  revised  and  improved.  Illustrated  with  three  hundred  and 
forty-four  wood-cuts.  In  one  large  and  handsome  octavo  volume  of  831  pages. 
Cloth,  $5.75  ;  leather,  $6.75.     {Jmt  issued.) 

A  PRACTICAL    TREATISE    ON    DISEASES    OF    THE  EYE. 

By  R.  Brudenell  Carter,  M.D.,  Ophthalmic  Surgeon  to  St.  George's  Hospital,  etc. 
Edited,  with  additions  and  test  types,  by  JouN  Grekn,  M.D.,  of  St.  Louis,  Mo.  In 
one  handsome  octavo  volume  of  about  600  pages  and  91  illustrations.     Cloth,  $3.75. 


HENRY  C.  LEA,  Philadelphia. 


OBSTETRICAL  TEXT-BOOKS. 


A  SYSTEM  OF  MIDAVIPERY:  including  tlie  Diseases  of  Preg- 
nancy ami  the  Puerperal  State.  By  William  LBisinfAN,  M.D.,  Regius  Professor  of 
Midwifery  in  the  University  of  Glasgow.  Second  American,  from  the  second  and 
enlarged  English  edition,  with  additions  by  J.  S.  Paruy,  M.D.,  Obstetrician  to  the 
Philadelphia,  Hospital.  In  one  very  handsome  octavo  volume  of  nearly  800  pages, 
with  about  200  illustrations  on  wood.     Cloth,  $5.00  ;   leather,  $6.00.      (Jutt  issued.) 

A  TPa^]ATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MID- 
WIFERY. By  W.  S.  Playfair,  M.D  ,  Professor  of  Obstetric  Medicine  in  King's 
College,  etc.  In  one  handsome  volume  of  576  pages,  with  166  illustrations,  and  two 
plates.     Cloth,  $4.00;  leather,  $5.00. 

THE  PRINCIPLES  AND  PRACTICE   OF  OBSTETRICS.     By 

Hugh  L.  Hodge,  M.D.,  Emeritus  Professor  of  Midwifery,  etc.,  in  the  University  of 
Pennsylvania.  Illustrated  with  large  lithographic  plftes  containing  159  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully 
printed  quarto  volume  of  550  double-columned  pages.     Cloth,  $14.00. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY  in  Reference  to  the  Process  of  Parturition.  By  Francis 
II.  Ramsbotha.m,  M.D.  With  adilitiona  by  W.  V.  Keating,  M.D.,  Professor  of 
Obstetrics,  etc.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large  and 
handsome  imperial  octavo  volume  of  650  pages,  with  04  plates  and  numerous  wood- 
cuts.    Leather,  $7.0  0. 

OBSTETRIC  APHORISMS  for  the  Use  of  Students  commencing 

Midwifery  Pr.ictice.  Second  American,  from  the  third  and  revised  London  edition, 
with  additions  by  E.  R.  IIutcuins,  M.D.  With  illustrations.  In  one  neat  12mo. 
volume.     Cloth,  $1.25. 

THE    THEORY    AND     PRACTICE    OF     MIDWIFERY.      \iy 

Fleetwood  Churchill,  M  D.,M  R.I.  A.  A  new  American,  from  a  lute  and  improved 
English  edition,  with  notes  and  additions  by  D.  F.  Cundie,  M.D..  Cloth,  .$4.00  ; 
leather,  $5.00. 

THE  PATHOLOGY  AND  TREATMENT  OF  CHILDBED.     By 

F.  WiNCKEL,  Professor  and  Director  of  the  Gynfficologieal  Clinic  in  the  University  of 
Rostock.  From  the  second  German  edition,  with  additions  by  the  author.  Trans- 
lated by  James  Read  Chadwick,  M.D.,  Clinical  Lecturer  on  Diseases  of  Women  in 
Harvard  University.    In  one  handsome  octavo  volume      Cloth,  $4.00.     {Just  issued.) 

EXTRA-UTERINE    PREGNANCY:    its    Clinical   History,   Diag- 

nosis,  Prognosif,  and  Treatment.  By  John  S.  Parry',  M.D.,  Obstetrician  to  the 
Philadelphia  Hospital,  Vice-President  of  the  Obstetrical  Society  of  Philadelphia,  etc. 
In  one  handsome  octavo  volume  of  274  pages.     Cloth,  $2.50.      (Just  issued.) 


THE  OBSTETRICAL  JOURNAL  OF  GREAT  BRITAIN  AND 

IRELAND;  including  Midwifery  and  the  Diseases  of  Children.  With  an  American 
Supplement,  edited  by  J.  V.  Ingham,  M.D.  A  monthly  periodical  of  ninety-six 
octavo  pages,  very  handsomely  printed.  Subscription,  $5.00  per  annum.  Single 
numbers,  50  cents  each. 


HENRY  C.  LEA,  Philadelphia. 


(late  lea  k  blanchaud's) 
OF 

MEDICAL  AND  SUEGIOAL  PUBLICATIONS. 


In  asking  the  attention  of  the  profession  tq  the  works  advertised  in  the  followinsr 
pages,  the  publisher  would  state  that  no  pains  are  spared  to  secure  a  continuance  of 
the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works 
not  kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  will  be  sent 
by  mail  post-paid  on  receipt  of  the  price,  but  no  risks  are  assumed  either  on  the 
money  or  the  books,  and  no  publications  but  my  own  are  supplied.  Gentlemen  will 
therefore  in  most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  Ii.lcstrated  Catalogue,  of  G4  octavo  pages,  handsomely  printed,  will  be  for- 
warded by  mail,  post-paid,  on  receipt  of  ten  cents. 

HENRY  C.  LEA. 

Nos.  706  and  708  Sansom  St.,  PHiLADELrniA,  October,  1876. 


ADDITIONAL  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICA]^  JOURNAL  OF  THE  MEDICAL  SCIEXCES. 

THEEE  MEDICAL  JOUENALS,  containing  over  2000  LARGE  PAGES, 
Free  of  Postage,  for  SIX  DOLLAES  Per  Annum. 

TERMS  FOB  1876: 

The  American  Journal  of  the  Medicai-  Sciences,  and  )  Five  Dollars  per  annum. 
TuE  Medical  News  and  Library,  both  free  of  postage,  j  in  advance. 

OPt 

The  American  Journal  of  the  Medical  Sciences,  published  quar-  ]  yj^  Dollars 
terly  (llnO  passes  per  annum) ,  with  I 

■    The  Medical  News  and  Library,  monthly  (384  pp.  per  annum),  and   ;-  per  annum, 

The  Monthly  Abstract  of  Mkdical  Sciknck  (592  pages  per  |  j^  advance, 
annum),  J 

SEPARATE  SUBSCRIPTIONS  TO 

The  American  Journal  of  the  Medical  Sciences,  when  not  paid  for  in  advance, 
Five  Dollars. 

The  Medical  News  and  Library,  free  of  postage,  in  advance,  One  Dollar. 

The  Monthly  Abstract  of  Medical  Science,  free  of  postage,  in  advance,  Two 
Dollars  and  a  Half. 

It  is  manifest  that  only  a  very  wide  circulation  can  enable  so  vast  an  amount  of 
valuable  practical  matter  to  be  supplied  at  a  price  so  unprecedentedly  low.  'I'iie  pub- 
Usher  therefore,  has  much  jrratification  in  stating  that  the  very  great  favor  with  which 
these  periodical's  are  regarded  by  the  profession  promises  to  ren<ler  the  enterprise  a 
peraanent  one  and  it  Ts  with  especial  pleasure  that  he  acknowledges  the  valuable 
assistance  spontaneously  rendered  by  so  many  of  the  old  subscribers  to  the  "Jour- 
nal "  who  have  kindly  made  known  among  their  friends  the  advantages  thus  offered, 
and'have  induced  them  to  subscribe.  Relying  upon  a  continuance  of  these  tnendly 
exertions  he  hopes  to  be  able  to  maintain  the  unexampled  rates  at  which  these  works 


iVnr  "  Thk  Obstetrical  Journal,"  see  p.  23.) 


2  Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 

are  now  offered,  and  to  succeed  in  his  endeavor  to  place  upon  the  table  of  every 
reading'  practitioner  in  the  United  States  the  equivalent  of  three  large  octavo  volumes, 
at  the  comparatively  trifling  cost  of  Six  Dollars  per  (uinum. 

These  periodicals  are  universally  known  for  their  high  professional  standing  in  their 
several  spheres. 

I. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 
Edited  by  ISAAC  HAYS,  M.D., 

is  published  Quarterly,  on  the  first  of  January,  April,  July,  and  October.  Each  num- 
ber contains  nearly  three  hundred  large  octavo  pages,  appropriately  illustrated  wher- 
ever necessary.  It  has  now  been  issued  regularly  for  over  fikty  years,  during  nearly 
the  whole  of  which  time  it  has  been  under  the  control  of  the  present  editor.  Through- 
out this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of  medical 
periodicals  both  at  home  and  abroad,  and  has  received  the  cordial  support  of  the  en- 
tire profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large  number 
of  the  most  distinguished  names  of  the  profession  in  every  section  of  the  United 
States,  rendering  the  department  devoted  to 

ORIGINAL     COMMUNICATIONS 

full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners.  Thus,  during 
1875,  articles  have  appeared  in  its  pages  from  nearly  one  hundred  gentlemen  of  the 
highest  standing  in  the  profession  throughout  the  United  States,* 

Following  this  is  the  "Review  Departjient,"  containing  extended  and  impartial 
reviews  of  all  important  new  works,  together  with  numerous  elaborate  "  Analytical 
AND  Bibliographical  Notices"  of  nearly  all  the  medical  publications  of  the  day. 

This  is  followed  by  the  "Quarterly  Summary  of  Improvements  and  Discoveries 
IN  THE  Medical  Sciences,"  classified  and  arranged  under  difl'ereut  heads,  presenting 
a  very  complete  digest  of  all  that  is  new  and  interesting  to  the  physician,  abroad  as 
well  as  at  home. 

Thus,  during  the  year  187.5,  the  "Journal"  furnished  to  its  subscribers  98  Orig- 
inal Communications,  95  Reviews  and  Bibliographical  Notices,  and  283  articles  in 
the  Quarterly  Summaries,  making  a  total  of  about  Five  Hundred  articles  emanating 
from  the  best  professional  minds  in  America  and  Europe. 

That  the  efi'orts  thus  made  to  maintain  the  high  reputation  of  the  "Journal"  are 
successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
national  exponent  of  medical  progress : — 

America  continues  to  take  a  great  place  in  this 
class  of  journals  (quarterlies),  at  the  head  of  which 
the  great  work  of  Dr.  Hays,  tlie  Aiiitrican  Juurnal 
of  the  Mecical  Sciences,  still  holds  its  ground,  as  our 
quotations  have  often  proved. — Dublin  Med.  Press 
and  Circular,  Jan.  31,  1872. 

Of  English  periodicals  the  Ldncet,  and  of  American 
the  Am.  -Juurnal  of  t lie  Medial  .Sciences,  are  to  be 
regarded  as  necessities  to  the  reading  practitioner. — 
iV  r.  Medical  Gazette,  Jan.  7,  1S7I. 

The  American  Juurnal  of  the  Medical  Sciences 
yields  to  none  in  the  amount  of  original  and  bor- 

And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Pub- 
lisher iu  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences"  has 
never  been  raised  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ;  and 
when  paid  for  iu  advance,  the  subscriber  receives  in  addition  the  "Medical  News  and 
Library,"  making  in  all  about  15UU  large  octavo  pages  per  annum,  free  of  postage. 

IT. 

THE  MEDICAL  NEWS  AND  LIBRARY 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  "News  Department"  presents  the  current  information  of  the  day,  with 
Clinical  Lectures  and  Hospital  Gleanings;  while  the  "Library  Department"  is  de- 
voted to  publishing  standard  works  on  the  various  branches  of  medical  science,  paged 

*  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.  Elaborate  articles  iuserttd 
by  the  Editor  are  paid  for  by  the  i'ublisher. 


rowed  matter  it  contains,  and  has  established  for 
itself  a  reputation  iu  every  country  where  medicine 
is  cultivated  as  a  science  — Brit,  and  For.  Med  -VUi- 
rury.  Review,  April,  Ii)71. 

This,  if  not  the  best,  is  one  of  the  best-conducted 
medical  quarterlies  in  the  English  language,  and  the. 
present  number  is  not  by  auy  means  inferior  to  its 
predece.ssors. — London  Lancet,-  Aug.  23,  1873. 

Almost  the  only  oue  that  circulates  everywhere, 
all  over  the  Union  and  in  Europe. — London  Medical 
Times,  Sept.  o,  IstJS. 


Henry  C.  Lea^s  Publications— (J?n.  Journ.  Med.  Sciences).         3 

separately,  so  that  they  can  be  removed  and  bound  on  compMion.  In  this  manner 
subscribers  have  received,  without  expense,  such  works  as  "  Watson's  Pkaotice  " 

I  ODD    AND    LOWMAN'S    PHYSIOLOGY,"     "  WeST    ON    CHri.DREX,"     "  M  ALG  AXON  F.'s    SUR- 

GERY,  'bTOKEs's  Lectukks  ON  Fever,"  &c.  .tc.  With  July,  1870,  will  be  commenced 
tlie  pub  ication  ot  Gossei.in  s  "  Clinical  Lectures  on  Surgery,"  trauslutcd  from  the 
i^rench  by  Lewis  A.  Stimson,  M.D.,  Sur-eon  to  the  Presbyterian  Hospital,  New  Yo-k 
(see  p.  26),  rendering  this  a  particularly  desirable  time  for  the  commencement  of  new 
subscriptions. 

As  stated  above,  the  subscription  price  of  the  "Medical  News  and  Library"  is 
One  Dollar  per  annum  in  advance;  and  it  is  furnished  without  charj-e  to  all  advance 
paying  subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 

in. 
THE  MONTHLY  ABSTRACT  OF  MEDICAL  SCIENCE. 

The  "Monthly  Abstract"  is  issued  on  the  first  of  every  month,  each  number  con- 
taining forty-eight  large  octavo  pages,  thus  furnishing  in  the  course  of  the  year  about 
SIX  hundred  pages.  The  aim  of  the  Abstra(;t  will  be  to  present  a  careful  condensa- 
tion of  all  that  is  new  and  important  in  the  medical  journalism  of  the  world,  and  all 
the  prominent  professional  periodicals  of  both  hemispheres  will  be  at  the  disposal 
of  the  Editors.  To  show  the  manner  in  which  this  plan  has  been  carried  out,  it  is 
sufficient  to  state  that  during  the  year  1875  it  contained — 

4'-i  Articles  on  Anatotui/  and  J'hysiohxjy. 

SO  "  "    3Iateria  Mrdica  and  Tlwraxteutics. 

204  "  "   Sli-dic.ine. 

1S3  "  «   Siiif/ery. 

US  "  "   Miflififcri/ and  Gi/nrprolof/i/. 

iff  "  "  Mi'dicnlJ'irisprttUvncc  <tnd  Toxicology. 

S  "  "    Hygiene — 

making  in  all  Six  Hundred  and  Twenty'-Nine  articles  in  a  single  year. 

'I'he  subscription  to  the  '•  Monthly  Abstract,"  free  of  postage,  is  Two  Dollar."? 
and  a  Half  a  year,  in  advance. 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  "American 
Journal  of  the  Medical  Sciences"  and  the  "Medical  News  and  J^ibrary,"  making 
in  all  about  'J'wenty'-one  Hundred  pages  per  annum,  the  whole //x-e  of  fioslaga,  for 
Six  Dollars  a  year,  in  advance. 

'I'he  first  volume  of  the  "  Monthly  Abstract,"  from  July  to  December,  1874,  can 
be  had  by  those  who  desire  to  have  complete  sets,  if  early  application  be  made,  for 
$1  f>0,  1  vol.  8vo  ,  of  300  pages,  cloth ;  also,  Vol.  IL  for  1875,  Svo  ,  600  pp.  cloth,  for 
%'i  00. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 
aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  }le 
trusts,  especially,  that  the  subscribers  to  the  "American  Medical  Journal"  will  cull 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  lie  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literatu;e 
on  a  footing  of  cheapness  never  heretofore  attempted. 

PEEMIUM  rOE  OBTAINING  NEW  SUBSOEIEEES  TO  THE  "JOUENAL." 

Any  yentlemau  who  will  remit  the  amount  for  two  subscriptions  for  1876,  one  of 
which  must  be  for  a  nev)  subscriber,  will  receive  as  a  i-remium,  free  by  mail,  a  copy  of 
"Flint's  Essays  on  Conservative  Medicine"  (for  advertisement  of  which  see  p.  15;, 
or  of  "Sturges's  Clinical  Medicine"  (see  p.  14),  or  of  the  new  edition  of  "Swayne's 
Oobstetric  Aphorisms"  (see  p.  24),  or  of  "Tanner's  Clinical  Manual"  (see  p.  5), 
or  of  "Chambers's  Restorative  Medicine"  (see  p.  16),  or  of  "West  on  NervouS 
Disorders  of  Children"  (see  page  21). 

*  *  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
welfto  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1876,  as  the  constant  increase  in  the  subscription  list 
almost  always  exhausts  the  quantity  printed  shortly  after  publication. 

^°  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  Mie  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  registered 
letters.     Address,  HENRY  C.  LE.4, 

Nos.  706  and  708  Sansom  St.,  Philadelphia,  Pa. 


Henry  C.  Lea's  Publications — (Dictionaries). 


jyUNGLISON  {ROBLEY),  M.D., 

"^"^  Late  Professor  of  InstUutea  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL   LEXICON;   A  Dictionary   of  Medical  Science:   Con- 
taining a  concise  eTcplanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters ;  Formula}  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  ol 
the  Terms,  and  the  French  and  other  Synonymes;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.     A  New  Edition.*    Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richard  J.  Dunglison,  M.I).     In  one  very  large  and  hand- 
Fome  royal  octavo  volume  of  over  1100  pages.     Cloth,  $6  50;  leather,  raised  bands,  $7  50. 
(Just  Issued.) 
The  object  of  th"e  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relatione, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.     Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en- 
viable reputation.  During  the  tf  n  years  which  have  elapsed  since  the  last  revision,  the  additior  8 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  author  labored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typographical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  ot  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 

We  are  glad  to  .-^ee  a  new  edition  of  thio  invaluable 
work,  and  to  tind  tliat  it  has  been  so  tborouglily  revised, 
and  80  greatly  iinproved.  'i'he  dictionary,  iu  its  pre- 
sent form,  is  a  mi  dical  library  in  iti^elf,  and  one  of 
w  hich  every  physician  should  be  i>ossessed. — aV.  1'.  Med. 


A  book  well  known  to  our  readers,  and  of  which 
every  American  ought  to  be  proud.  When  the  learned 
author  of  the  work  yjassed  away,  probably  all  of  us 
feared  lest  the  book  should  net  maintain  its  place 
in  the  advancing  science  whoKe  terms  it  delines.  For- 
tunately, Dr.  Bichard  J.  I)unglisou,  having  a.«sisted  his 
father  in  the  revision  of  several  editions  of  th(?  work, 
and  having  been,  therefore,  trained  iu  the  methtds  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it,  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  po  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  as  a  work  of  the  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  tafk  which  Dr.  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  state  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
pre.'eut  edition.  'Witbout  i  ccupj  ing  more  space  with  the 
theme,  we  congratulate  the  editor  on  the  successful 
completion  of  his  labors,  and  hope  he  may  reap  the  well- 
earned  reward  of  profit  and  honor. — Phxla.  iltti.  Times, 
Jan.  3, 1874. 

About  the  first  book  purchased  hj  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  a  i-i>ie  qua  nfl^.  In  a 
science  so  exten.«ive,  and  with  such  collaterals  as  medi- 
ane,  it  is  as  much  a  necessity  a!  -o  to  the  practising 
physician.  To  meet  the  wants  o'.  students  and  most 
physicians,  the  dictionary  must  be  condensed  while 
compirehensive,  and  practical  whi'e  perspicacious.  It 
was  because  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  Englisli  language.  In  no 
former  revision  have  the  alteration:-  and  additions  been 
BO  great.  More  than  six  thousand  new  subjects  and  terms 
have  been  added.  The  chief  terms  hp.ve  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
Skrrangemeut  which  greatly  facilitates  reference.  We 
may  safely  confirm  the  hope  ventured  by  the  editor 
"  that  the  work,  which  possesses  for  him  a  filial  as  well 
as  an  individual  interest,  will  be  found  worthy  a  con- 
tinuance of  the  position  so  long  accorded  to  it  as  a 
standard  authority." — Cincinnati  Clinic,  Jan.  10,  1874. 


Journal,  i'eb.  1874. 

M'ith  a  history  of  forty  years  of  unexampled  success 
and  universal  indorjemeut  by  the  meuicwi  pioies.'^ion  of 
the  western  continent,  it  would  be  presumption  in  any 
living  medical  American  to  essay  its  review.  Ko  re- 
viewer, however  able,  can  add  to  its  fame;  no  captious 
critic,  however  caii>tic,  can  remove  a  single  stone  from 
its  firm  and  enduring  foundation.  It  is  destined.  a.<  a 
colossal  monument,  to  perpetuate  the  solid  and  riclily 
deserved  fame  of  liobley  Dunglison  to  coming  genera- 
tions. The  large  additions  made  to  the  vocabulary,  we 
think,  will  be  welcomed  by  the  profes.-iion  as  supplying 
the  want  of  a  lexicon  fuily  up  with  the  march  oi  sci- 
ence, which  has  been  increasingly  felt  for  some  years 
past.  The  accentuation  of  terms  is  very  complete,  and, 
as  far  as  we  have  been  able  to  examine  it,  very  excel- 
lent. We  hope  it  may  be  the  means  of  securing  greater 
uniformity  of  pronunciation  among  medical  meu. — At- 
lanta Med.  and  Hurg.  Joum.,  Feb.  1874. 

It  would  he  mere  waste  of  words  in  us  to  express 
our  admiration  of  a  work  which  is  so  universally 
and  deservedly  appreciated.  The  most  admirable 
work  of  its  kind  in  the  Kaglish  language. — Glasgow 
Medical  Journal,  January,  ISfJti. 

A  work  to  which  there  is  no  equal  in  the  English 
language. — Edinburgh  Medical  Journal. 

Few  works  of  the  class  exhibit  a  grander  monument 
of  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  sufficient  to  testify  to  its 
asefnlness,  and  to  the  great  service  conferred  by  Dr. 
Robley  Dunglison  on  the  profession,  and  indeed  on 
others,  by  its  iane..— London  Lancet,  May  13,  1S65. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Gazette. 


TJOBLYN  {RICHARD  D.),  M.D. 


A  DICTIONAKY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  Isaac    HAra, 
M.D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  60  ;  leather,  $3  00. 
It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student'*  labi©.— Bo«fA«rii 
Med  and  Surg.  Journal. 


Hen«y  C.  Lha's  Publications— (JIfaimah  I. 


jI  CEXTVRT  of  AMERICAS'  MEniCIS'E.  ITTfi-ls-fi.    n«  D„c-(or,  F  H 


JDOD  WELL  [Q.  F).  F.R.A.S..  .yc 


A  DICTIOXARY  OF  SCIEXCE:  Comprising  Astronomy    Chem 

istry    Dynamics,   Electricity,    Heat.    Hydrodynnmics    Hydrostatics,    Li^ht.    Ma^neti^n 
Mechanics    Meteorology    Pneumatics.  Sound,  nnd  Statics.     Preceded  by\n  Es     y  on  t"; 
History  of  the  Physical  Sciences.     In  one  handsome  octavo  volume  of  694  naites\nd 
many  Illustrations  :  cloth,  $5.  P"'o«»>  <i'hi 


N- 


EILL  {JOHN),  M.D.,    and.    gMITH  {FEANCIS  G.),  M.D., 

Prof,  of  the  InstitiUes  of  Mtdicine.  in  the  Univ  of  Penna 

AN    ANALYTICAL    COMPENDIUM   OF   THE   VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12m(. 
volume,  of  about  one  thousand -pages,  with  374  wood  cuts,  cloth,  $4;  strono-ly  bound  in 
leather,  with  raised  bands,  $4  75.  ° 


The  Compend  of  Drs,  Neill  and  Smith  is  incompara- 
bly the  most  valuable  work  of  its  class  ever  published 
la  this  country.  Attempts  have  been  made  in  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetrics,  Materia  Medica, 
and  Chemistry  into  a  single  manual;  but  the  opera- 
tion has  signally  failed  in  the  hands  of  all  up  to  the 
advent  of  "Neill  and  Smith's"  volume,  which  is  quite 
a  miracle  of  success.  The  outlines  of  the  whole  are 
admirably  drawn  and  illustrated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 


If  the  student  of  every  class.— .ft'.  0.  Med.  and  Sura 

There  are  but  few  students  or  practitioners  of  me- 
ticine  unacquainted  with  the  former  editions  of  this 
inassnming  though  highly  instructive  work  The 
•vhole  science  of  medicine  appears  to  have  bepn  sifted 
\a  the  gold-bearing  sands  of  El  Dorado,  and  the  pre- 
cious factstreasured  up  in  this  little  rolnme  A  cm- 
plete  portable  library  so  condensed  that  the  student 
may  make  it  his  constant  pocket  companioo.— ITft^f- 
ern  Lancet. 


TTARTSHORNE  [HENRY),  M.  D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A   CONSPECTUS    OF   THE    MEDICAL   SCIENCES;   containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practical  Medicine' 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  lar^e 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.     Cloth,  $4  25  ;  leather,  $5  00.     (Lately  Issued.) 


The  work  before  us  has  already  .snccessfully  assert- 
ed its  claim  to  the  confidence  aud  favor  of  the  profes- 
sion ;  it  but  remains  for  us  to  say  that  in  the  present 
edition  the  whole  work  has  bepii  fully  overhauled 
and  brought  up  to  the  present  status  of  the  science.— 
Atlanta  Med.  and  Surg.  Journal,  Sept.  1S71. 

The  work  is  intended  as  an  aid  to  the  medical  stu- 
dent, and  as  such  appears  to  admirably  fulfil  its  ob- 
ject by  itsexcellent  arrangement,  thefiill  compilalion 


and  the  clear  and  instructive  illustrations  in  somo 
parts  of  the  work  —American  Journ.  of  Pharmar,, 
Philadelphia,  July,  1874.  ' 

The  volume  will  be  found  useful,  not  only  to  stu- 
dents, but  to  many  others  who  may  desire  to  ref^e^h 
their  memories  with  tlio  smallest  po-isible  expendi- 
ture of  time.— xV   Y   Med.  Journal,  Sflpt.  l»H. 

The  student  will  find  thii  the  most  coaveiiient  and 
useful  book  of  the  kind   -in  which    he   ran  lav  hia 


ject  by  itsexcellent  arrangement,  tneiuucompiiaiioo     useiui  oook  or   tne  Kina   -in  winch    tip   ran  lav  1 
of  facta,  the  perspicuity  aud  terseness  of  laugiiage,  1  hand.— Paci;^c  Med.  ant  Hurg.  Journ.,  Aug.  1574 

JUDLOW  {J.L.),  M.D. 

A   MANUAL   OF   EXAMINATIONS   upon   Anatom.y,   Physiologj, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica.  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustriitions.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  ofiBce  examination  of  students,  and  for  those  preparing  for  graduation. 


rfANNER  [THOMAS  HA  WKES),  M.D.,  ^r. 

■'■  A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 
NOSIS. Third  American  from  the  Second  London  Edition.  Revised  and  Enlarged  by 
TiLBUEY  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
Ac.    In  one  neat  volume  small  ]2mo.,  of  about  375  pages,  cloth,  $150. 

*^*  By  reference  to  the  "  Prospectus  of  Journal"  on  page  3,  it  will  be  seen  that  thi.«  work  is 
offered  as  a  premium  for  procuring  new  subscribers  to  the  "Ameiucau  Journal  of  the  Medical 
Sciences." 


Henry  C.  Lea's  Publications — {Anatomy). 


flRAT  (HENRY),  F.R.S., 

Lecturer  on  Anntomy  at  St.  George^ a  Hospital,  London. 

ANATOMY,    DESCRIPTIVE    AND    SURGICAL.      The  Drawings  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissec- 
tions jointlj'  by  the  Author  and  Dr.  Carter.     A  new  American,  from  the  fifth  enlarged 
and  improved  London  edition.     In  one  magnificent  imperial  octavo  volume,  of  nearly  900 
pages,  with  465  large  and  elaborate  engravings  on  wood.     Price  in  cloth,  $6  00  ;   lea- 
ther, raised  band.s,  $7  00.     (Jiist  Issued.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.     The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  alj 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.    They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Notwithstanding  the  enlargement  of  this  edition,  it  has  been  kept  at  its  former  very  moderate 
price,  rendering  it  one  of  the  cheapest  works  now  before  the  profe.asion. 

The  illnstrationi-  are  beautifally  execnted,  and  ren- 1  From  time  to  time,  as  snccessive  editions  have  ap- 
der  tliiti  work  an  indispensable  adjunct  to  the  library  ppared,  we  have  had  much  pleasure  in  expressing 
of  the  surgeon.  This  remark  applies  with  great  force  the  general  judgment  of  the  wonderful  excellence  of 
to  those  surgeons  practising  at  a  distance  from  oar  !  Gray's  Anatomy. — Cincinnati  Lancet,  Jaly,  1S70. 


large  cities,  as  the  opportunity  of  refreshing  their 
memory  by  actual  dissection  is  not  always  attain- 
able.—  Canada  Mtd   Journal,  Aug.  1870. 

The  work  is  too  well  known  and  appreciated  by  the 
profession  to  need  any  comment.  No  medical  man 
can  alford  to  be  without  it,  if  its  only  merit  were  to 
serve  as  a  reminder  of  that  which  so  soon  becomes 
forgotten,  when  not  called  into  frequent  nse,  vii.,  the 


Altogether,  it  is  unquestionably  the  most  complete 
and  serviceable  textbook  in  anatomy  that  has  ever 
been  presented  to  the  student,  and  forms  a  striking 
contrast  to  the  dry  and  perplexing  volumes  on  the 
same  subject  through  which  their  predecessors  strug- 
gled in  days  gone  by. — N.  T.  Med.  Record,  June  13, 
1870. 

To  commend  Gray's  Anatomy  to  the  medical  pro- 


relations  and  names  of  the  complex  organism  of  the  fe«gion  is  almost  as  much  a  work  of  supererogation 
human  body.  The  present  edition  is  much  improved,  ^s  it  would  be  to  give  a  favorable  notice  of  the  Bible 
—  California  Med.  Gazette,  July,  1S70.  |  j^  ,1jq  religious  press.     To  say  that  it  is  the  most 

Gray's  Anatomy  has  been  so  long  the  standard  of  I  complete  and  conveniently  arranged  text-book  of  its 
perfection  with  every  student  of  anatomy,  that  we  •  kind,  is  to  repeat  what  each  generation  of  students 
need  do  no  more  than  call  attention  to  the  improve-  has  learned  as  a  tradition  of  th*  elders,  and  verified 
ment  in  the  present  edition. — Detroit  Review  of  Med.  by  personal  experience. — N  T.  Med.  Gazette,  Dec. 
and  Pknrm.,  Aug.  1870.  <  17,  1870. 


CiMITH  [HENR  Y  E.),  M.D.,         and     TJORNER  (  WILLIAM  E.\  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna.,  &c.  Late  Prof,  of  Anatomy  in  the  Univ.  of  Penna.,  Ac . 

AN    ANATOMICAL    ATLAS,  illustrative  of  the   Structure  of  the 

Human  Body.     In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundrec  and 

fifty  beautiful  figures.     $4  50. 
The  plan  of  this  Adas,  which  renders  it  so  peca-  I  the  kind  that  has  yet  appeared  ;  and  we  must  add, 
liarly  convenient  for  the  student,  and  its  superb  ar-  [  the  very  beautiful  manner  in  which  it  is  "got  np," 
tislical  execution,  have  been  already  pointed  out.  We  j  is  so  crpditable  to  the  country  as  to  be  flattering  to 
must  congratulate  the  student  upon  the  completion     our  national  pride. — American  Medical  Journal. 
of  this  Atlas,  as  it  is  the  most  convenient  work  of  I 

^JHA  RPEY  (  WILLIAM),  M.D.,     and       Q  VAIN  {JONES  ^  RICHARD). 
HUMAN  ANATOMY,  Revised,  with  Notes  and  Additions,  by  Joseph 

Leidy,  M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two 
large  octavo  volumes,  of  about  l.SOO  pages,  with  511  illustrations;  cloth,  $6  00. 
The  very  low  price  of  this  standard  work,  and  its  completeness  in  all  departments  of  the  subject, 
should  command  for  it  a  place  in  the  library  of  all  anatomical  students. 

JJODGES  {RICHARD  if.),  M.D., 

Late  Demonstrator  of  Anatomy  in  the  Medical  Department  of  Harvard  University. 

PRACTICAL  DISSECTIONS.     Second  Edition,  thoroughly  revised.     In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00. 
The  object  of  this  work  is  to  present  to  the  anatomical  student  a  clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  couise  of  dissections.  The  author  has 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subject  in  the  form  which  many  years' 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
the  favor  with  which  it  has  heretofore  been  received. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOLOGY.  I      In  2  vols.  8vo.,  of  over  1000  pages,  with  more  th»» 
Eighth  edition,  extensively  revised  and  modified.  1     300  wood-cuts  :  cloth,  $6  00. 


Henry  C.  Lea's  Publications — (Anatomy). 


-^ILSON  [EEASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.    Edited 

by  W.H.  GoBRECHT,  M.D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.     Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.     In 
.one  large  and  handsome  octavo  volume,  of  over  600  large  pages;  cloth,  $4  00;  leather 
$5  00. 
The  publisher  trusts  that  the  well-earned  reputation  of  this  long-established  favorite  will  be 
iaore  than  maintained  by  the  present  edition.     Besides  a  very  thorough  revision  by  the  author,  it 
has  been  most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  in- 
troducing everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a  complete  text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  llumau  Ana- 
tomy.    The  amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  faci  tha« 
th«  present  edition  contains  over  one-fourth  more  mutter  than  the  last,  rendering  a  smaller  type 
anil  an  enlarged  page  requisite  to  keep  the  volume  within  a  convenient  sise.     The  author  has  Lot 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  iis 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.    The  editor 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased 
the  number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
importance. 

TJEATH  {CHRISTOPHER),  F.  R.  C.S., 

■^■*-  Teacher  of  OperativK  Surgery  in  University  College,  London. 

PRACTICAL   ANATOMY:   A   Manual   of  Dissections.     From  the 

Second  revised  and  improved  London  edition.     Edited,  with  add'itious,  by  W.  \V.  Keen, 

M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 

In  one  handsome  royal  12mo.  volume  of  678  pages,  with  247  illustrations.    Cloth.  $3  60  ; 

leather,  $4  00.      {Lately  Fublished.) 

tainiog  its  hold  apon  the  slippery  slopes  of  aaatoiay. 
—at.  Louin  Med.  and  Surg.  Journal,  Alar.  10,  1871. 

It  appears  to  us  certain  that,  as  a  guide  in  dissec- 
tLun,  aud  as  a  work  coataiaiug  facts  ol  anatoui^'  ia 
orief  and  easily  uuderstuod  I'orui,  this  luauual  is 
complete.  This  work  contains,  also,  very  perlccl 
illustrations  of  parts  which  can  thus  be  mure  easily 
inderstood  and  studied;  in  this  respect  it  compares 
with  which  we  are  acquainted  ;  resembling  Wilson  |  favorably  vith  works  of  much  greater  pretension 


Dr.  Keen,  the  American  editor  ol  this  work,  in  his 
preface,  says:  "In  preseuting  thin  American  edition 
of  'Heath's  Practical  Anatomy,'  1  feel  that  I  have 
been  instrumental  in  supplying  a  want  lung  felt  for 
a  redl  diaeector's  manual,"  and  this  assertion  of  its 
aditor  we  deem  is  fully  justified,  after  an  examina- 
tion of  its  contents,  for  it  is  really  auexoellenl  work. 
Indeed,  we  do  not  hesitate  to  say,  the  best  of  its  class 


In  terse  and  clear  description,  excelling  most  of  the 
so-called  practical  anatomical  dissectors  in  the  scope 
of  the  subject  aud  practical  selected  matter.  .  .  . 
In  reading  this  work,  one  is  forcibly  impressed  with 
the  great  paius  the  author  takes  to  impress  the  sub- 
ject upon  the  mind  of  the  student  He  is  full  of  rare 
aud  pleasing  little  devices  to  aid  memory  in  main- 


Such  manuals  of  anatomy  are  always  favorite  works 
with  medical  students.  We  would  earnestly  recom- 
mend this  one  to  their  attention  ;  it  has  excellences 
which  make  it  valuable  as  a  guide  in  disseciiug,  aa 
well  as  in  studying  anatomy. — JSuJfaki  Medical  and 
SurgicalJour nal,  Jan.  1871. 


nELLAMY{E.),  F.R.C.S. 

THE  STUDENT'S  GUIDE  TO  SURGICAL  ANATOMY:  A  Text- 
Book  for  Students  preparing  for  their  Pass  Examination.     With  engravings  on  wood.     In 
one  handsome  royal  i:imo.  volume.     Cloth,  $2  25.  .  (Just  Issued.) 
We  welcome  ilr.  Bellamy's  work,  as  a  contribu- 
tion to  the  study  of  regional  anatomy,  of  equal  value 
to  the  student  aid  the  surgeon.     It  is  wruien  in  a 
clear  aud  concise  stylt^,  aud  its  practical  suggestions 
add  largely  to  theiniereol  altacliiiig  to  its  tecluiical 
details  — Chicago  Med.  Jbxamiuer,  March  1,  ls74. 

We  cordially  congratulate  Air.  Bellamy  upon  hav- 
ing produced  it. — Med.  Times  and  Gaz. 


We  cannot  too  highly  recommead  it. — StudeiWa 
Journal. 

Mr.  Bellamy  has  spared  no  pains  to  produce  a  real- 
ly reliable  student  s  guide  to  surgical  anatomy — one 
which  all  candidates  for  surgical  degrees  may  con- 
sult with  advantage,  and  which  posseses  much  ori- 
ginal waiter. — Mtd.  tresis  and  Circular. 


JUACLISE  {JOSEPH). 

SURGICAL   ANATOMY.     By  Joseph   Maclise,  Surgeon.    In  one 

volume,  very  large  imperial  quarto;  with  68  large  and  splendid  plates,  drawn  in  the  best 
style  and  beautifully  colored,  containing  190  figures,  many  of  them  the  size  ol  life ;  together 
with  copious  explanatory  letter-press.  Strongly  and  handsomely  bound  in  cloth.  Price 
$14  00. 


We  know  of  no  work  on  surgical  anatomy  which 
«an  compete  with  it. — Lancet. 

The  work  of  Maclise  on  surgical  anatomy  Is  of  the 
highest  value.  In  some  respects  it  is  the  best  publi- 
cation of  its  kind  we  have  seen,  and  is  worthy  of  a 
place  in  the  library  of  any  medical  man,  while  the 

Htndent  could  scarcely  make  a  belter  investment  than  . - 

t^T-TZwJernJonrnalo/Medi<HnenndSnrgery.    admirable  treatise.-iJ.<*ion  Med.  and  Surg.  Jour:., 

No  such  lithographic  illustrations  of  surgical  re- 1 


jioQS  have  hitherto,  we  think,  been  given.  While 
■,he  operator  is  shown  every  vessel  and  nerve  where 
tn  operation  is  contemplated,  the  exact  anatomist  is 
refreshed  by  those  clear  and  distinct  dlhsecuouo, 
which  every  one  must  appreciate  who  has  a  particle 
of  enthusiasm.  The  English  medical  press  has  quite 
exhausted  the  words  of  praise,  lu  recommending  this 


rJARTSHORNE  {HENRY),  M.D., 

■iJ-  Professor  of  Hygiene,  eCe  ,  in  the  Univ.  o/Penna 

HANDBOOK  OF   ANATOMY  AND 


PHYSIOLOGY.     Second  Edi- 


^     Tn  onprovall2mo.  volume,  with  220  wood  cuts;  cloth,  $1  75.   (Just  Isyuet'.) 


8 


Henry  C.  Lea's  Publications — (Physiology). 


MARSHALL  {JOHN),  F.  R.  S., 

^^  Professor  of  Surgery  in  University  College,  London,  Ac. 

OUTLINES  OF  PHYSIOLOGY,  HUMAX  AND  COMPARATIYF. 

With  Additions  by  Francis  Gurnkt  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medi- 
cine in  the  University  of  Pennsylvania,  Ac.  With  numerous  illustrations.  In  one  large 
and  handsome  octavo  volume,  of  1026  pages,  cloth,  $6  50  ;  leather,  raised  bands,  $7  50. 

In  fact,  in  every  respect,  Mr.  Marshall  has  present-  tive,  with  -which  we  are  acquainted.  To  speak  of 
•d  us  with  a  most  complete,  reliable,  and  scientific  ,  this  work  in  the  terms  ordinarily  used  on  such  occa- 
work,  and  we  feel  that  it  is  worthy  our  warmest  |  aions  would  not  be  agreeable  to  ourselves,  and  wonld 
eouimendation. — St.  Louis  Med.  Reporter,  Jan.  1S69.     fail  to  do  justice  to  its  author.     To  write  such  a  book 

vrr    J     v.Tiv        ■     ■     .1,     T7     1-  1,  1  requires  a  varied  and  wide  ranee  of  knowledge,  con 

Wedoub  If  there  is  in  the  English  language  any  .i^^erable  power  of  analysis,  correct  judgment,  skU] 
compend  ol  phy.siolcgy  more  u-sefol  to  the  student  j^  arrangement,  and  conscientious  spiril-Zonl^i, 
thuD  this  wovk.— St.  Louxs  Med.  a7id  Surg.  Journal,  j^nncet  Feb  22  186S  ""-"""'""o  "i"'"-  -uvhum-h 
Jan.  ]S69.  '         '      '    .     ' 

It  quite  fulfils,  in  our  opinion,  the  author's  design  !  Tberearefew,  ifany,  more  accomplished  anatomists 
of  making  it  truly  e<f«oa(ionann  its  character-which  i  ^i^i  physiologists  thanthe  distinguished  professor  ot 
Is,  perhaps,  the  highest  commendation  that  can  be  f'^'-*"^  '^^.^"^^""'y  ,^^-"^86  ;  and  he  has  long  en- 
asked.-im.  Journ.  Med.  Sciences,  Jan.  1S69.  J ^y^d  the  highest  reputation  as  a  teacher  of  physiol- 

ogy,posses8ingremarkable  powers  ofclearexpobition 

We  may  now  congratulate  him  on  having  com- '  and  graphic  illustration.  We  have  rarely  the  plea- 
pleled  the  latest  as  well  as  the  best  summary  of  mod-  sure  of  being  able  to  recommend  a  text-book  so  unre- 
ern  physiological  science,  both  human  and  compara-  ■  servedlyasthis. — British Med.Journal,  Jan. 25,1863. 


c 


'ARP ENTER  {WILLIAM  B.),  M.D.,  F.R.S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  appli- 
cations to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A  new 
American  from  the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations. 
Edited,  with  additions,  by  Francis  Gurnky  Smith,  M.  D.,  Professor  of  the  Institutes  oi 
Medicine  in  the  University  of  Pennsylvania,  Ac.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  900  large  pages,  handsomely  printed;  cloth,  $5  60  ;  leather,  raised  bands, 
$6  50. 

We  doubt  not  it  is  destined  to  retain  a  strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  io 
onr  colleges. — Virginia  Medical  Journal. 


With  Dr.  Smith,  we  confidently  believe  "that  the 
present  will  more  than  sustain  the  enviable  reputa- 
tion already  attained  by  former  editions,  of  being 
one  of  the  fullest  and  most  complete  treatises  on  the 
subject  in  the  English  language."  We  know  of  none 
from  the  pages  of  which  a  i^atisfaclory  knowledge  of 
the  physiology  of  the  human  organism  can  be  as  well 
obtained,  none  better  adapted  for  the  use  of  such  as 
take  up  the  study  of  physiology  in  its  reference  to 
the  institutes  and  practice  of  medicine. — Am.  Jour. 
Med.  Sciences. 


The  above  is  the  title  of  what  is  emphatically  the 
great  work  on  physiology  ;  and  we  are  conscious  that 
it  would  be  a  useless  effort  to  attempt  to  add  any- 
thing to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
influence,  that  it  is  our  authority. — Atlanta  Med. 
Journal. 


DY  THE  SAME  AUTHOR. 

PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.    New  Ameri- 

can,  from  the  Fourth  and  Revised  London  Edition.     In  one  large  and  handsome  octavo 
volume,  with  over  three  hundred  beautiful  illustrations.    Pp.752.    Cloth,  $5  00. 
As  a  complete  and  condensed  treatise  on  its  extended  and  important  subject,  this  work  becomes 

a  necessity  to  students  of  natural  science,  while  the  very  low  price  at  which  it  is  offered  places  it 

within  the  reach  of  all. 


l^IRKES  {WILLIAM  SENHOUSE),  M.D. 

A  MANUAL  OF  PHYSIOLOGY.     Edited  by  W.  Morrant  Baker, 

M.D.,  F.R.C.S.      A  new  American  from  the  eighth  and  improved  London  edition.     With 
about  two  hundred  and  fifty  illustrations.     In  one  large  and  handsome  royal  12mo.  vol- 
ume.    Cloth,  $3  25  ;  leather,  $3  75.      {Lately  Issued.) 
Kirkes'  Physiology  has  long  been  known  as  a  concise  and  exceedingly  convenient  text-book, 
presenting  within  a  narrow  compass  all  that  is  important  for  the  student.     The  rapidity  with 
which  successive  editions  have  followed  each  other  in  England  has  enabled  the  editor  to  keep  it 
thoroughly  on  a  level  with  the  changes  and  new  discoveries  made  in  the  science,  and  the  eighth 
edition,  of  which  the  present  is  a  reprint,  has  appeared  so  recently  that  it  may  be  regarded  as 
the  latest  accessible  exposition  of  the  subject. 


On  the  whole,  there  is  very  little  in  the  book 
which  either  the  student  or  practitioner  will  notfind 
of  practical  value  and  consistent  with  our  present 
knowledge  of  this  rapidly  changing  science  ;  and  we 
have  no  hesitation  in  expressing  our  opinion  that 
this  eighth  edition  is  one  of  the  best  handbooks  on 
physiology  which  we  have  in  our  language. — N.  ¥. 
Med.  Record,  April  15,  1873. 

This  volume  might  well  be  used  to  replace  many 
of  the  physiological  text-books  in  use  in  this  conn- 
try.  It  represents  more  accurately  than  the  works 
of  Dalton  or  Flint,  the  present  state  of  our  knowl- 
edge of  most  physiological  questions,  while  it  is 
much  less  balky  and  far  more  readable  than  the  lar- 


ger text-books  of  Carpenter  or  Marshall.  The  book 
is  admirably  adapted  to  be  placed  In  the  hands  of 
students. — Boston  Med.  and  Surg.  Journ.,  April  10, 
1S73. 

In  its  enlarged  form  it  is,  in  onr  opinion,  still  the 
best  book  on  physiology,  most  useful  to  the  student. 
—Phila.  Med.  Times,  Aug.  30,  1873. 

This  is  undoubtedly  the  best  work  for  students  of 
physiology  extant. — Cincinnati  M(d.  News,  Sept.  '73. 

It  more  nearly  represents  the  present  condition  of 
physiology  than  any  other  text-book  on  thesubject.— 
Detroit  Rev.  of  Med.  Piiarm.,  Kov.  1S73. 


Henry  C.  Lea's  Publications — (Physiology.) 


n ALTON  {J.  C),  M.D., 

-'-^  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  Ac. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Desifrned  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  tboroufrUly  revised  and  enlnrjred, 
with  three  hundred  and  sixteen  illustrations  on  wood.  In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.     Cloih,  $5  50  ;  leather,  $6  50.     {Now  Ready.) 

From  the  Freface  to  the  Sixth  Edition. 

In  the  present  edition  of  this  book,  while  every  pnrt  has  received  a  careful  revision,  the  ori- 
ginal plan  of  arrangement  has  been  changed  only  so  far  as  was  necessary  for  the  introduction  of 
new  material. 

The  additions  and  alterations  in  the  test,  requisite  to  present  concijely  the  growth  of  positive 
physiological  knowledge,  have  resulted  in  spite  of  the  author's  earnest  efforts  at  condensation, 
in  an  increase  of  fully  fifty  per  cent,  in  the  matter  of  the  work.  A  change,  however,  in  the  ty- 
pographical arrangement  has  accommodated  these  additions  without  undue  enlargement  in  the 
bulk  of  the  volume. 

The  new  chemical  notation  and  nomenclature  are  introduced  into  the  present  edition,  ns  hav 
ing  now  so  generally  taken  the  place  of  the  old,  that  no  confu.^ion  need  result  from  the  change. 
The  centigrade  system  of  measurements  for  length,  volume,  and  weight,  is  also  adopted,  these 
measurements  being  at  present  almost  universally  employed  in  original  physiological  investiga- 
tions and  their  published  accounts.  Temperatures  are  given  in  degrees  of  the  centigrade  scale, 
usuallj'  accompanied  by  the  corresponding  degrees  of  Fahrenheit's  scale,  inclosed  in  brackets. 
Kew  York,  September,  1875. 


During  tliH  past  few  years  several  new  works  on  pliy- 
siology,  and  new  editions  of  old  works,  have  appeared, 
competing  for  the  favor  of  the  medical  student,  but  none 
■will  rival  this  new  edition  of  Dalton.  As  now  enlarged, 
it  will  be  found  al.«o  to  be.  in  general,  a  satisfa(^tory  work 
of  reference  for  the  practitioner. — Chicago  Med.  Journ. 
and  Examiner,  Jan.  1876. 

Prof.  Dalton  has  discussed  conflicting  theories  and 
conclusions  regarding  physiological  questions  with  a 
fairness,  a  fulness,  and  a  conciseness  which  lend  fresh- 
ness and  vTgor  to  the  entire  book.  But  his  discussions 
have  been  so  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  at  best 
exist  in  the  minds  of  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  be  led  into 
grave  errors  while  making  them  a  study. — Tlie,  Medical 
Record,  Feb.  19, 1876. 

The  revision  of  this  great  work  has  brought  it  forward 
with  the  physiological  advances  of  the  day,  and  renders 
it,  as  it  has  ever  heen,  the  finest  work  for  students  ex- 
tant.— Nashville  Journ.  of  Med.  and  Surg.,  Jan.  1876. 

For  clearness  and  perspicuity,  Dalton's  Physiology 
commended  itself  to  tlie  student  years  agi,  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiolfigy  has,  however,  made  many  ad- 
vances since  then  — and  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  alireast  of  the  times.  The  new  chemical 
notation  and  nomenclature  have  also  been  introduced 
into  the  present  edition.  Notwithstanding  the  multi- 
plicity of  text-books  on  physiology,  this  will  lose  none 


of  its  old  time  popularity.  The  mechanical  execution 
of  the  work  is  all  th  it  couUl  be  desired. — Peninsular 
Journal  nf  Miidicine,  Dec.  1875. 

This  popular  text-book  on  physiology  comes  to  us  in 
its  sixth  edition  with  the  .addition  of  about  tifty  per  cent, 
of  new  matter,  chiefly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  system,  where  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  amf  additions,  that  keep  the  work  well 
vip  to  the  times,  its  continued  popularity  may  b(*  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  admirably 
done. — St.  Louis  Meil.  and  .Surg.  Journ  ,  Dec.  1875. 

We  heartily  welcome  this,  the  sixth  edition  of  this 
admirable  text  hook,  than  which  there  are  none  of  equal 
brevity  more  valuable.  It  is  cordially  recommendeil  by 
the  Professor  of  Physiology  in  the  University  of  Louisi- 
ana, as  by  all  competent  teachers  in  the  United  States 
and  wherever  the  Knglish  language  is  read,  this  book 
has  been  appreciated.  The  present  edition,  with  its  .316 
admirably  executed  illustrations,  has  been  carefully 
revised  and  very  much  enlarnod,  although  its  bulk  docs 
not  seem  perceptibly  increased. — A'eio  Orleans  Medtcal 
and  Surgical  Journal,  March,  1876. 

The  present  edition  is  very  much  superior  to  every 
other,  not  only  in  that  it  brings  the  subject  up  to  the 
times,  but  that  it  doss  so  mon;  fully  and  satisfactorily 
than  any  previous  edition.  Take  it  altogether,  it  re- 
mains, in  our  humble  opinion,  the  best  text  book  on 
phvsiology  in  any  land  or  language. — Tlie  Clinic,  Nov. 
6,  1875. 


D 


UNGLISON  {ROBLEY),  M.D., 

Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.    Eighth  edition.    Thovoiighly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.     In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1600  pages,  cloth,  $7  00. 


TEHMANN  (C.  O.). 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  George  E.  Day,  M.  D.,  F.  R.  S.,  Ac,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations 
selected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendi.x  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  cloth,  $6  00. 


T5r  TBE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY. 


L^x-<  ^j-ci-xj  vy-L    y^^^^^.^^^.^^^   ^ -      Tran.slated  from  the 

German,  with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory 
Essay  on  "Vital  Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Pennsyl- 
vania. With  illustrations  on  wood.  In  one  very  handsome  octavo  volume  of  336  pages, 
oloth,  $2  26. 


10 


Henry  C.  Lea's  Publications — (Chemistry). 


ATTFIELD  (JOHN),  Ph.D., 

Proffxxor  of  Prncticnl  ChfimWry  to  the  Pharmnneuticfr?  Sonietp  of  Great  Britain.  *c. 

CHEMISTRY,    GENERAL,  MEDICAL,  AND  PHARMACEIJTTCAL  ; 

includinpr  the  Cbemistry  of  the  U.  R.  Pharmacopoeia.  A  Manual  of  the  General  PrincipleF 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Fifth  Edition,  revised 
by  the  author.  In  one  handsome  royal  12mo.  volume  ;  cloth,  $2  75  ;  leather,  $3  25. 
(Lately  Issued.) 

engatted  in  mpdirine  and  pharmacy,  and  we  heartily 
cninmend  it  to  onr  readers. — Canada  Lancet,  Oct. 
1871. 

When  the  original  Entrllsh  edition  of  this  work  was 
pnhlished.  we  had  ooc-iRlon  to  express  onr  high  ap- 
preciation of  its  worth,  and  also  to  review,  in  con- 
siderable detail,  the  ni;fin  feature-^  of  the  book.  As 
the  arrangpinent  of  stibjects,  and  the  mnin  part  of 
the  text  of  the  present  edition  are  .similar  to  the  for- 
mer publication,  it  will  be  needless  for  ns  to  go  over 
the  ground  a  second  time  ;  we  may.  however,  call  at- 
tention to  a  marked  advantage  possessed  by  the  Ame- 
rican work — we  allude  to  the  introduction  of  the 
chemistry  of  the  preparations  of  the  United  States 
Pharmacopoeia  as  well  as  that  relating  to  the  British 
authority.  —  Canadian  Pharmaceutical  Journal, 
Nov.  1871. 

Chemistry  has  borne  the  name  of  being  a  hard  sub- 
ject to  master  by  the  student  of  medicine,  and 
chiefly  because  so  much  of  it  consists  of  compounds 
only  of  interest  to  the  scientific  chemist;  in  this  work 
such  portions  are  modified  or  altogether  left  out,  and 
in  the  arrangement  of  the  subject  matter  of  the  work, 
practical  utility  is  sought  after,  and  we  think  fully 
attained      Wecommend  it  for  its  clearness  and  order 


No  other  American  publication  with  which  we  are 
acquainted  covers  the  same  ground,  or  does  it  so  well. 
In  addition  to  an  admirable  expo=^  of  the  facts  and 
principles  of  general  elementary  chemistry,  the  au- 
thor has  presented  us  with  a  cond='Dsed  mass  of  prac- 
tical matter,  just  such  as  the  medical  student  and 
practitioner  needs. — Cincinnati  Lanref,  Mar   1874 

We  commend  the  work  heartily  as  one  of  the  best 
lext-books  extant  for  the  medical  student. — Detroit 
Skv.  of  Mfd.  and  Phnrm.,  Feb.  1S72. 

The  best  work  of  the  kind  in  the  English  language. 
JV.  Y.  Psychological  Journal,  Jan.  1S72. 

The  work  is  constructed  with  direct  reference  to 
the  wants  of  medical  and  pharmaceutical  students  : 
and,  although  an  English  work,  the  points  of  differ- 
ence between  the  British  and  United  States  Pharma- 
copeias are  indicated,  making  it  as  useful  here  as  in 
England.  Altogether,  the  book  is  one  we  can  heart- 
ily recommend  to  practitioners  as  well  as  stadents. 
—]C.  T.  Med.  Journal,  Dec.  1871. 

It  differs  from  other  text-books  in  the  following 
particulars:  first,  in  the  exclusion  of  matter  relating 
to  compounds  which,  at  present,  are  only  of  interest 
to  the  scientific  chemist;  secondly,  in  containing  the 
chemistry  of  every  substance  recognized  officially  or 

In  genera'l,  as  a  remedial  agent.    If  will  be  found  a  I  to  both  teacher  and  pupil.— Ore^ron  Med.  and  Surg. 
most  valuable  book  for  pupils,  assistants,  and  others  I  Reporter,  Oct.  1871. 


F 


OWNES  {GEORGE),  Ph.D. 


A  MANUAL  OP  ELEMENTARY  CHEMISTRY;   Theoretical  and 

Practical.    With  one  hundred  and  ninety-seven  illustrations.    A  new  American,  from  the 
tenth  and  revised  London  edition.     Edited  by  Robert  Bridges,  M.  D.     In  one  large 
royal  12mo.  volume,  of  about  860  pp.,  cloth,  !?!2"75  ;  leather,  S3  25.      (Lately  Issned.) 
This  work  is  so  well  known  that  it  seems  almost    ither  work  that  has  greater  claims  on  the  physician, 
superfluous  for  us  to  speak  about  it.     It  has  been  a    pharmaceutist,  or  student,  than  this.     We  cheerfully 
favorite  text-book  with  medical  students  for  years,    recommend  it  as  the  best  text-book  on  elementary 
and   its  popularity   has   in    no  respect   diminished,    chemistry,  and  bespeak  for  it  the  careful  attention 
Whenever  we  have  been  consulted  by  medical  stu-    -)f  students  of  pharmacy.— C/iicap'O  P/iarwiaef*<,  Aug. 
dents,  aa  has  frequently  occurrfed,  what  treatise  on    1869. 
chemistrv  they  should  procure,  we  have  always  re- 
commended Eownes'.  for  we  regarded  it  as  the  best.        Here  is  a  new  edition  which  has  been  long  watched 
There  is  no  work  that  combines  so  many  excellen-    for  by  eager  teachers  of  chemistry.     In  its  new  garb, 
ces.      It  is  of  convenient  size,  not  prolix,  of  plain    and  under  the  editorship  of  Mr.  Watts,  it  has  resumed 
perspicuous  diction,   contains  all    the   most  recent   its  old  place  as  the  most  successful  of  text-books.— 
discoveries,  and  is  of  moderate  -prica.— Cincinnati .  Indian  Medical  Gazette.  Jan.  1.  1S69 
Mi'd.  Repertory,  Aug.  1869.  ^^  ^.„  ^„„,i„„,_  ^^  heretofore  to  hold  the  first  rank 

Large  additions  have  been  made,  especially  In  the    is   a  text-book  for  students  of  medicine. — Chicago 
department  of  organic  chemistry,  and  we  know  of  no    Med.  Examiner,  Aug.  1869. 

QDLING  ( WILLIAM), 

^-"^  Lecturer  on  Chemistry  at  St.  Bartholometo's  Bo.tpitiil,  Ac. 

A  COURSE  OF  PRACTICAL  CHEMISTRY,  arranged  for  the  Use 

of  Medical  Students.    With  Illustrations.    From  the  Fourth  and  Revised  London  Edition. 
In  one  neat  royal  12mo.  volume,  cloth,  $2. 


(lALLOWAY  [ROBERT),  F.G.S., 

^•~"  Prof,  of  Applied  Cherni.itry  in  the  Royal  College  of  Science  for  Ireland,  &c. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.     From  the  Fifth  Lon- 

don  Edition.     In  one  neat  royal  12mo.  volume,  with  illustrations;  cloth,  $2  50.     (Just 
Issued. ) 

The  success  which  has  carried  this  work  through  repeated  editions  in  England,  and  its  adoption 
fts  a  text-book  in  several  of  the  leading  institutions  in  this  country,  show  that  the  author  has  suc- 
ceeded in  the  endeavor  to  produce  a  sound  practical  manual  and  book  of  reference  for  the  che- 
mical student. 

Prof  Galloway's  books  are  deservedly  in  high  i  We  regard  this  volume  as  a  valuable  addition  to 
esteem,  and  this  American  reprint  of  the  fifth  edition  the  chemical  text-books,  and  as  particularly  calcn- 
(1869)  of  his  Manual  of  Qualitative  Analysis,  will  be  lated  to  instruct  the  student  in  analytical  researches 
acceptable  to  many  American  students  to  whom  the  |  of  the  inorganic  comp'>nnds,  the  important  vegetable 
English  edition  is  not  accessible. — Am.  Jour,  of  Sci-  i  acids,  and  of  cmpounds  and  vi<ric!us  secretions  and 
ence  and  Arts,  Sept.  1872.  I  excretions  of  animal  origin. — Am.  Journ.  of  Pharm., 

I  Sept.  1872. 


Henry  C.  Lea's  Publications — (Chemistry). 


11 


'DLOXAM  iC.  L.). 

■*-'  Professor  of  Cheinixlry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.     From  the  Second  Lon- 

don  Edition.  In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illustra- 
tions. Cloth,  $4  00  ;  leather,  $5  00.  {Lately  Issued.) 
It  has  been  the  author's  endeavor  to  produce  a  Treatise  on  Chemistry  sufficiently  comprehen- 
sive for  those  studying  the  science  as  a  branch  of  general  education,  and  one  which  a  student 
may  use  with  advantage  in  pursuing  his  chemical  studies  at  one  of  the  colleges  or  medical  schools. 
The  special  attention  devoted  to  Metallurgy  and  some  other  branches  of  Applied  Chemistry  renders 
the  work  especially  useful  to  those  who  are  being  educated  for  employment  in  manufacture. 
We  have  iu  this  work  a  complete  and  most  excel-    experimeut  have  been  worked  up  with  especial  care, 


lent  text-book  for  the  vise  of  schools,  and  can  heart- 
ily recommeud  it  as  such. — Boston  Med.  and  Surg. 
Journ.,  May  28,  1874. 

Of  all  the  numerous  works  upon  elementary  chem- 
istry that  have  been  published  within  the  last  few 
years,  we  can  point  to  none  that,  in  fulness,  accuracy, 
and  simplicity,  can  surpass  this  ;  while,  in  the  num- 
ber and  detailed  descriptions  of  experiments,  as  also 
lu  the  profuseness  of  its  illustrations,  we  believe  it 
stands  above  any  similar  work  published  in  this  coun- 
try  The  statements  made  are  clear  and  con- 
cise, and  every  step  proved  by  an  abundance  of  ex- 
periments, which  excite  our  admiration  as  much  by 
their  simplicity  as  by  their  direct  conclusiveness. — 
Chicngo  Med.  Examiner,  Nov.  1.5,  1873. 

It  is  seldom  that  in  the  same  compass  so  complete 
and  interesting  a  compendium  of  the  leading  facts  of 
chemistry  is  offered. — Druggists'  Circular,  Nov.  '73. 

The  above  is  the  title  of  a  work  which  we  can  most 
conscientiously  recommend  to  students  of  chemistry. 
It  is  as  easy  as  a  work  on  chemistry  could  be  made, 
at  the  same  lime  that  it  presents  a  full  account  of  that 
science  as  it  now  stands.  We  have  spoken  of  the 
work  as  admirably  adapted  to  the  wants  of  students  ; 
it  is  quite  ::s  well  suited  to  the  requirements  of  prac- 
titioners who  wish  to  review  their  chemistry,  or  have 
occasion  to  refresh  their  memories  on  any  point  re- 
lating to  it.  In  a  word,  it  is  a  book  to  be  read  by  all 
who  wish  to  know  what  is  the  chemistry  of  the  pre- 
sent day. — American  Practitioner,  Nov.  187,3. 

Among  the  various  works  upon  general  chemistry 
issued,  we  know  of  none  that  will  supply  the  average 
wants  of  the  student  or  teacher  better  than  this. — 
Indiana  Journ.  of  Med.,  Nov.  1873. 

We  cordially  welcome  this  American  reprint  of  a 
work  which  has  already  won  for  itself  so  substantial 
a  reputation  in  England.  Professor  Bloxam  has  con- 
densed into  a  wonderfully  small  com  ;ass  all  the  im- 
portant, principles  and  facts  of  chemical  science. 
Thoroughly  imbued  with  an  enthusiastic  loveforthe 
science  he  expounds,  he  has  stripped  it  of  all  need- 
less technicalities,  and  rounded  oat  its  hard  outlines 
by  a  fulness  of  illustration  that  cannot  fail  to  attract 
and  delight  the  student.     The  details  of  illustrative 


and  many  of  the  experin)ents  described  are  both  new 
and  striking. — Detroit  Rev.  of  Med.  and  Phartn., 
Nov.  1873. 

One  of  the  best  text-books  of  chemistry  yet  pub- 
lished.— Chicago  Med.  Journ.,  Nov.  187!;. 

This  is  an  excellent  work,  well  adapted  for  the  be- 
ginner and  the  advanced  student  of  chemistry. — Am. 
Journ.  of  Phnrm  ,  Nov.  1873. 

Probably  the  most  valuable,  and  at  the  same  time 
practical,  text-book  on  general  chemistry  extant  ia 
our  language. — Kansas  City  Med.  Journ.,  Dec.  1873. 

Prof.  Bloxam  possesses  pre-eminently  the  inestima- 
ble gift  of  perspicuity.  It  is  a  pleasure  to  read  his 
books,  for  he  is  capable  of  making  very  plain  what 
other  authors  frequently  have  left  very  obscure. — 
Va.  Clinical  Record,  Nov.  1873. 

It  would  be  difficult  for  a  practical  chemist  and 
teacher  to  find  any  material  fault  with  this  most  ad- 
mirable treatise.  The  author  has  given  us  almost  a 
cyclopedia  within  the  limits  of  a  convenient  volume, 
and  has  done  so  without  penning  the  useless  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulkof  many  cumbrous  works.  The  progressive  sci- 
entist is  not  disaiipoin ted  when  he  looks  for  the  record 
of  new  and  valuable  processes  and  discoveries,  while 
the  cautious  conservative  does  not  find  its  pages  mo- 
nopolized by  uncertain  theories  and  speculations.  A 
peculiar  point  of  excellence  is  the  crystallized  form  of 
expression  in  which  great  truths  are  expres-sed  ia 
very  short  paragraphs.  One  is  surprised  at  the  brief 
space  allotted  to  an  important  topic,  and  yet,  after 
reading  it,  he  feels  that  little,  if  any  more,  should 
have  been  said.  Altogether,  ii  is  seldom  you  see  a 
text-book  so  nearly  faultless.— 6'j»ici7j/»a<i  Lancet, 
Nov.  1873. 

Prjfessor  Bloxam  has  given  us  a  most  excellent 
and  useful  practical  treitise.  His  t)6t>  pages  are 
crowded  with  facts  and  experiments,  nearly  all  well 
chosen,  and  many  quite  new,  even  to  scientific  men. 
.  It  is  astonishing  how  much  infoimatiou  he  often 
conveys  in  a  few  paragraphs.  We  might  quote  fifty 
instances  of  \.\di.— Chemical  News. 


'^^OCTLINES  OF  ORGANIC  CHEMISTRY.     Translated  with  Ad- 
ditions from  the  Eighth  German  Edition.     By  Ira  Remsen    M.D.,  Ph.D.,  Profe.ssor  of 
Chemistry  and  Physics  in  Williams  College,  Mass.     In  one  handsome  volume,  royal  I2mo. 
of  650  pp.,  cloth,  $.3. 
As  the  numerous  editions  of  the  original  attest,  this  work  is  the  leading  text-book  and  standard 
aufhority  throughout  Germany  on  its  important  and  intricate  subject-a  posttioti  won  for  U  by 
the  clearness  and  conciseness  which  are  its  distinguishing  characteristics.     The  translation  has 
been  executed  with  the  approbation  of  Profs.  Wohler  and  F.ttig,  and  numerous  -'IJ't  o"«  and 
alterations  have  been  introduced,  so  as  to  render  it  in  every  respect  on  a  level  with  the  most 
advanced  condition  of  the  science.      ^ . 

jyO  WMAN  {JOHN  E.),M.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.     Edited 

by  C    L.   Bloxam,  Professor  of  Practical  Chemistry  in  King's  College,  London.       Sixth 
American,  from  the  fourth  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo., 
pp.  .351,  with  numerous  illustrations,  cloth,  $2  25. 
"DY  THE  SAME  AUTHOR.     (Lat-ly  Innned)        

INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.     Sixth  American,  from  the  sixth  and  revised  London  edition.    With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  12mo.,  cloth,  $2  25. 


K  TAPP'S  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  Arts,  and  to  .Manufactures.  With  American 
ad^itinns.  bv  Prof.  WALTER   R.   JOHHSON.     In  tWO 


very  handsome  octavo  volamee,  with  600   wood 
engravings,  oloth,  $6  O^. 


12       Henry  0.  Lea's  Publications — (Mat  Med.  and  Therapeutics). 
JpARRISH  [ED  WARD), 

Late  Professor  of  Materin  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.    Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and 
Prescriptions.     Fourth  Edition,  thoroufjhly  revised,  by  TnoMAS  S.   Wiegand.      In  one 
handsome  octavo  volume  of  977  pages,  with  280  illustrations;  cloth,  $5  60;  leather,  $6  50 
{Lately  Issued.) 
The  delay  in  the  appearance  of  the  new  U.  S.  Pharmacopoeia,  and  the  sudden  death  of  the  au- 
thor, have  postponed  the  ]ireparation  of  this  new  edition  beyond  the  period  expected.     The  notes 
and  memor:inda  left  by  Mr.  Parrish  have  been  placed  in  the  hands  of  the  editor,  Mr.  Wie;^and, 
who  has  labored  assiduously  to  embody  in  the  work  all  the  improvements  of  pharmaceutical  sci- 
ence which  have  been  introduced  during    he  last  ten  years.     It  is  therefore  hoped  that  the  new 
edition  will  fully  maintain  the  reputation  which  the  volume  has  heretofore  enjoj-ed  as  a  standard 
text-book  and  work  of  reference  for  all  engaged  in  the  preparation  and  dispensing  of  medicines. 
Of  Dr.  Pariish's  great  work  on  pharmacy  it  ouly  i  an  honored  place  on  our  own  bookshelves. — Dublin 
renuiius  to  be  said  that  the  editor  has  accomplislied  ,  Med.  Press  a7id  Circular,  Aug.  12,  1874. 
his  work  so  well  as. to  maintain,  in  this  fourth  edi-  |      y^^  expressed  our  opinion  of  a  former  edition  in 
tion,  the  high  standard  of  excellence  which  it  had    jg,.„j.  ^f  i,aq„alified  praise,  and  we  are  in  no  mood 
attained  in  previous  editions,  under  the  editorship  of    ^^  detract  from  that  opinion  in  rf  lerence  to  the  pre- 
its  accomplished  author.     This  has  not  been  acconv     ^^^  edition,  the  preparation  of  which  has  fallen  into 
plished  without  much  labor,  and  many  additions  and     competent  hands.  It  is  a  book  with  which  no  pharma^ 
improvements,  involving  changes  in  the  arrangement_    (.jg,  (.j^„  dispense,  and  from  which  no  physician  can 
of  the  several  parts  of  the  work,  and  the  addition  of    f^j,  („  derive  much  information  of  value  to  him  in 
much  new  matter.     With  the  modilieatious  thus  et-    practice.— Poci>-c  Med  and  Surg.  Journ.,  June,  '74. 
fected  it  constitutes,  as  now  presented,  a  compendium  I 

of  the  science  and  art  indii-pensable  to  the  pharma-  ]  With  these  few  remarks  we  heartily  commend  the 
cist,  and  of  the  utmost  value  to  every  practilioner  work,  and  have  no  doubt  that  it  will  maintain  its 
of  medicine  desirous  of  familiarizing  himself  with  '  old  reputation  as  a  textbook  for  the  student,  and  a 
the  pharmaceutical  preparation  of  the  articles  which  I  work  of  reference  for  the  more  experienced  physl- 


he  prescribes  for  his  patients. — Chicago  Med.  Journ., 
July,  1874. 

The  work  is  eminently  practical,  and  has  the  rare 
rnerit  of  being  readable  and  interesting,  while  it  pre- 


cian   and   pharmacist. —  Chicago   Med.   Examiner, 
June  1.3,  1874. 

Perhaps  one,  if  not  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lau- 


serves  a  strictly  scieniifle  character.  The  wliole  work  ,  gunge  has  emanated  from  the  transatlantic  press, 
reflects  the  greatest  credit  on  author,  editor,  and  pub-  |  "  Parrish's  Pharmacy"  is  a  well-known  work  on  this 
lisher  It  will  convey  some  idea  of  the  liberality  which  ,  side  of  the  water,  and  the  fact  shows  us  that  a  really 
has  been  bestowed  upou  its  production  when  we  men-  useful  work  never  becomes  merely  local  in  its  fame, 
tion  that  there  are  no  less  than  280  carefully  executed  j  Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
illustrations.  In  conclusion,  we  heanily  recommend  '  posthumous  edition  of  "  Parrish"  has  been  saved  to 
the  work,  not  only  to  pharmacists,  but  also  to  the  '  the  public  with  all  the  mature  experience  of  its  au- 
multitude  of  medical  practitioners  who  are  obliged  !  thor.  anu  perhaps  none  the  worse  for  a  dash  of  new 
to  compound  their  own  medicines.     It  will  ever  hold    blood. — Lond.  Pharin.  Journal,  Oct.  17,  1S74. 


OTILLE  {ALFRED),  M.D., 

A3  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Descripti(/n  and  Historj. 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols,  of  about  2000 
pages.     Cloth,  SIO;  leather,  $12.      {Just  Issued.) 

The  care  bestowed  by  the  author  on  the  revision  of  this  edition  has  kept  the  work  out  of  the 
market  for  nearly  two  years,  and  has  increased  its  size  about  two  hundred  and  fifty  pages.  Not 
withstanding  this  enlargement,  the  price  has  been  kept  at  the  former  very  moderate  rate. 

It  is  unnecessary  to  do  much  more  than  to  an-  I  of  the  present  edition,  a  whole  cyclopsedia  of  thera- 
nounce  the  appearance  of  the  fourth  edition  of  this  i  peutics. — Chicago  Medical  Jotirnal,¥eh.  1875. 
well  known  and   excollent  work.— JSr«.  arid   For.         The  magnificent  work  of  Professor  Stille  is  known 
Med.-Chir.  Heview,  Oct  lh7.j.  wherever  the  English  language  is  read,  and  the  art 

For  all  who  desire  a  complete  work  on  therapeutics  of  medicine  cultivated  ;  known  so  well  that  no  enco- 
aud  materia  medica  for  reference,  in  cases  involving  miuiii  of  ours  could  brighten  its  fame,  and  no  unfa- 
niedico-legal  questions,  as  well  as  for  information  i  vorable  criticism  could  tarnish  its reputatioij. — Phil- 
concerning  remedial  agents.  Dr.  Still^'s  is  "par  ex-  I  adelphia  Mtd.  Times,  Dec.  12,  1874. 
celleiice"  the  work.  The  work  being  out  of  print,  by  The  rapid  exhaustion  of  three  editions  and  the  uni- 
the  exhaustion  of  former  editions  the  author  has  laid  versal  favor  with  which  the  work  has  been  received 
the  profession  under  renewed  obligations,  by  the  l  i^y  (ho  medical  profession,  are  sufficient  proof  of  its 
careful  revision,  important  additions,  and  timely  re-  excellence  as  a  repertory  of  practical  and  useful  in- 
issuing  a  work  not  exactly  supplemented  by  any  formation  for  the  phvsician.  The  edition  before  us 
other  in  the  English  language,  if  in  any  language.  f„iiy  sustains  this  verdict,  as  the  work  has  been  care- 
The  mechanical  execution  handsomely  sustains  the  j  fuUy  revised  and  in  some  portions  rewritten,  bring- 
wcll-known  skill  and  good  taste  of  the  publisher.—  jng-jt  up  ,„  the  pre.<ent  time  by  the  admission  of 
St.  Louis  Med.  and  Surg.  Journal,  Dec.  1874.  |  chloral  and  crotonchloral,  nitrite  of  amyl,  bichlo- 

The  prominent  feature  of  Dr.  Still^'s  great  work  i  ride    of  methylene,    methylic   ether,   lithium  j,coi^ 


is  sound  good  sense.  It  is  learned,  but  its  learning 
is  of  inferior  value  compared  with  the  discriminating 
judgment  which  is  shown  by  its  author  in  the  dis- 
cussion of  his  subjects,  and  which  renders  it  a  trust- 
worthv  guide  in  the  sick-room. — Am.  Practitioner, 
Jan.  187j. 

From  the  publication  of  the  first  edition  "Still6's 
Therapeutics"  has  been  one  of  the  classics;  its  ah' 


pounds,    gelseminnm,    and    other    remedies. — Am. 
Journ.  of  Pharmacy,  Feb.  )87o. 

We  can  hardly  admit  that  it  has  a  rival  in  the 
multitdde  of  its  citations  and  the  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  i)lace  in  the  physician's  library;  not,  indeed,  as 
fully  representing  the  present  siale  of  knowledge  in 
pharmacodynamics,  but  as  by  far  the  most  complete 


sence  from  our  libraries  would  create  a  vacuum  i  treatise  upon  the  clinical  and  practical  side  of  the 
which  could  be  filled  by  no  other  work  in  the  Ian-  '  question. — Boston  Mtd.  and.  Surg.  Journal,  Nov.o, 
guage,  and  its  presence  supplies,  in  the  two  volumes  '  1S74. 


Henry  C.  Lea's  Publications— ^i{fa^.  Med.  and  Therapeutics).       13 
QRIFFITH  [ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physician!  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  Joiis  M. 
Maisch,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavovolumeof  about  800  pages,  cloth,  $4  50  ;  leather,  $5  50.    (Jnst  Issued.) 

This  work  has  long  been  known  for  the  vast  amount  of  information  which  it  present;"  in  a  con- 
densed form,  arranged  for  easy  reference.  The  new  eiiition  has  received  the  most  careful  revi- 
sion at  the  competent  hands  of  Profe.«sor  Maisch,  who  h;is  brought  the  whole  up  to  the  standard  of 
the  most  recent  authorities.  More  than  eighty  new  headings  of  remedies  have  been  introduced, 
the  entire  work  has  been  thoroughly  remodelled,  and  wh.atever  has  seemed  to  he  obsolete  has  been 
omitted.  As  a  comparative  view  of  the  United  States,  the  British,  the  German,  and  the  French 
Pharmacopeias,  together  with  .an  immense  amount  of  unofficinal  formulas,  it  affords  to  the  prac- 
titioner and  pharmaceutist  an  aid  in  their  daily  avocations  not  to  be  found  elsewhere,  while  three 
indexes,  one  of  "Diseases  and  their  Remedies,"  one  of  Pharmaceutical  Names,  and  a  Ueneral 
Inde.T,  afford  an  easy  key  to  the  alphabetical  arrangement  adopted  in  the  text. 

The  young  practitioner  will  find  tlie  work  inralu-  i      To  the  druggist  a  good  formulary  is  gimnly  ioilis- 
able  in  suggesting  eligible  modes  of  administering  I  pensable,  and  perhap.s  no  formulary  has  ])eeu  nrire 
many  remedies. — Am.  Journ.  of  Pharni.,  Feb.  1874.  I  extensively  used  than  the  well-kuown  work  b«fore 
n  »^  .n?i>  >     1^  ,  ,        ,  us.     Many  physician.s  have  to  offlriate,  also,  as  drag- 

Our  copy  of  Griffith  s  Formulary  after  long  use,  gists.  This  istrue  especially  of  the  country  physi- 
firstin  the  dispensing  shop,  and  afterwards  in  our  eian,  and  a  work  which  shall  teach  him  the  means 
medical  practice,  had  gradually  fallen  behind  in  the  ]  ,,y  ^hjci,  ,o  administer  or  combine  his  remedies  in 
ouward  march  of  materia  medica,  pharmacy,  and  |  the  most  efflcacious  and  pleasant  manner,  will  al- 
rherapeutics,  until  we  had  ceased  to  con.sult  it  as  a  ^avs  hold  its  place  upon  his  shelf.  A  formulary  of 
daily  book  of  reference.      So  completely  has  Prof.  ' 

Maisch  reformed,  remodelled,  and  rejuvenated  it  in 
the  new  edition,  we  shall  gladly  welcome  it  back  to 


our  tai)le  again  beside  Dunglison,  Webster,  and  Wood 
&  Bache.  The  publisher  could  not  have  been  more 
fortunate  in  the  selection  of  an  editor.  Prof.  Maisch 
is  eminently  the  man  for  the  work,  and  he  has  done 
it  thoroughly  and  ably.  To  enumerate  the  altera- 
tions, amendments,  and  additions  would  be  an  end- 
less task  ;  everywhere  we  are  greeted  with  the  evi- 
dences of  his  labor.  Following  the  Formulary,  is  an 
addendum  of  useful  Recipes,  Dietetic  Preparations, 
List   of  Incorapatibles,   Posological   table,   table   of 


this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  practice.— Cmcinraafi  Olinie,  Feb.  21,  1S74. 

The  Formulary  has  already  proved  itself  accepta- 
ble to  the  medical  profession,  and  we  do  not  hesitate 
to  say  that  tbe  third  edition  is  much  improved,  and 
of  greater  practical  value,  in  consequence  of  the  care- 
ful revision  of  Prof  Maisch.— C/ticag'o  Med.  Exam- 
iner, March  \.i,  1874. 

A  more  complete  formulary  than  it  is  in  its  pres- 
ent form  the  pliarmacist  or  physician  could  hardly 
desire.  To  the  first  some  such  work  is  indi-peasa- 
ble,  and  it  is  hardly  les.^  essential  to  the  practitioner 


Pharmaceutical  Names,  Officinal  Preparations  and  j  who  compounds  his  own  medicines.  .Much  of  what 
Directions,  Poisons.  Antidotes,  and  Treatment,  and  1  is  contained  in  the  introduction  ought  to  be  corn- 
copious  indices,  which  afford  ready  access  to  all  parts  |  mitted  to  memory  by  every  student  of  mediuiaa. 
of  the  work.     We  unhesitatingly  commend  the  book     As  a  help  to  physicians  it  will  be  found  iuvaluablo, 

and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind. 
—  The  American  Practitioner,  Louisville,  July,  '71. 


as  being  the  best  of  its  kind,  within  our  knowledge 
— Atlanta  Med.  atid  Surg.  Journ.,  Feb.  1S74, 


PLLTS  {BENJAMIN-),  11.  D. 

THE  MEDICAL  FORMULARY:  being  a  Collection  of  Prescriptions 

derived  from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America 
and  Europe.  Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.  Twelfth  edi- 
tion,  carefully  revised  and  much  improved  by  Albert  H.  Smith,  M.  D.  In  one  volume  8v». 
of  376  pages,  cloth,  $3  00. 


iEREIRA  [JONATHAN),  M.D.,  F.R.S.  and  L.S. 

MATERIA  MEDICA  AXD  THERAPEUTICS;  being  an  Abridg- 
ment of  the  late  Dr.  Pereira's  Elements  of  Materia  Medica,  arranged  in  conformity  with 
'  the  British  Pharmacopoeia,  and  adapted  to  the  use  of  Medical  Practitioners,  Cherainta  and 
Druggists  Medical  and  Ph.irmaceutical  Students,  Ac.  By  F.  J.  Farhb.  M.D.,  Senior 
Phvsician  to  St.  Bartholomew's  Hospital,  and  London  Editor  of  the  British  Pharmacopoeia; 
assisted  by  Robekt  Bentley,  M.R.C.S.,  Professor  of  M.ateria  Medica  and  Botany  to  the 
Pharmaceutical  Society  of  Great  Britain ;  and  by  Robert  \Var.«gton  F.R.S.,  tbem.cTil 
Onerator  to  the  Society  of  Apothecaries.  With  numerous  additions  and  references  to  the 
United  States  PharmacopoeiL,  by  Horatio  C.  Wood,  M.D..  Professor  of  Bo  any  .n  the 
University  of  Pennsylvania.  In  one  large  and  handsome  octavo  volume  of  J"-»«  «>o«ely 
prS  pages,  with  236  illustrations,   cloth.  $7  00;   leather,  raised  bands.  «S  00. 


DHNGLisoN-s  NEW  REMEmEs  WITH  FOKMrL^ ,  ^^^i^^:^^^'^^^^^::^;^^::::::'^^ 

^^^i^^!^^^^'^^^^^^^^      ^J^:^.^a...iTH,M.l,.Onevo...vo..pp.loOO; 

^l^io  Se^SS^I^^I^A- ™  I  ^-S^. -^^  1^^  Z  .^^LT.fl 

vation.     From  the  second  London  edition.     1  vol.  j     «Xme,  pp.  178,  cloth.    60  cents, 
royal  12iho.,  cloth.    ¥1  00. 


14 


Henry  C.  Lea's  Publications — (Pathology,  <fec.). 


B 


RUNTON  (T.  LAUDER).  M.D., 

Lecturer  on  Materia  2I'''ticii  and  Thera'pe.uiics  (it  St  Bartholomtw's  Bo.sj/ital,  Ac. 

A  MANUAL   OF    MATERIA    MEDICA    AND    TIIERArEUTICS. 

INCLUDING  THE  PHARMACY,  THE  PHYSIOLOGICAL  ACTION,  AND  THE  THE- 
RAPEUTICAL USES  OF  DRUGS.     In  one  neat  octavo  volume.      {Prf-jjciritig.) 


PEN  WICK  {SAMUEL),  M.D., 

-*-  Assi stunt  Vhy.iician  to  the  London  Ho.9pifal. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enlarged  English  Edition.     With   eighty-four  illustrations  on  wood. 
In  on§  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.      (Jnst  Issued.) 


Of  the  many  guid^-books  on  medical  diatruof-is, 
claimed  to  be  written  for  tlie  special  inst'uciion  of 
students,  tlii«  is  the  best.  The  author  is  evidently  a 
well  read  and  accomplished  physician,  and  he  knows 
how  to  'each  practical  medicine.  The  charm  of  sim- 
plicity is  not  the  least  int-  restingfeaturein  the  man- 
neriu  which  Dr.  Feuwick  conveys  instruction.  There 
are  few  books  of  this  size  on  practical  medicine  that 
contain  so  much  and  convey  it  so  well  as  tbe  volume 
before  as,  I*  is  a  book  we  can  sincerely  recommend 
to  the  student  fir  direct  instruction,  and  to  the  prac- 
titioner as  a  ready  and  useful  aid  to  his  memory. — 
Am.  Jo  urn.  of  Syphilographx/,  Jan.  187-1. 

It  covers  the  ground  of  medical  diagnosis  in  a  con- 


cise, practical  manner,  well  calculated  to  assist  the 
student  in  forming  a  correct,  thorough,  and  system- 
atic method  of  examination  and  diagnosis  of  disease. 
The  illu.sirations  are  numerous,  and  finely  executed. 
Those  illustrative  of  the  microscopic  appearnnce  of 
morbid  tissue,  &c  ,  are  especially  clear  and  di.stiuct. 
— Chicago  Med.  Examiner.  Nov.  lf7.S. 

So  far  superi.ir  to  any  offered  to  students  that  tbe 
colleges  of  this  country  should  recommend  it  to  their 
respt-clive  classes. — N.  0.  Med.  and  Surg.  Journ., 
March,  1874. 

This  little  book  ought  to  he  in  the  possession  of 
every  medical  student. — Boston  Medical  and  Surg. 
Journ.,  Jan.  15,  187-i. 


nREEN  (T.  HENRY),  M.D., 

^-^  Lecturer  on  Pathology  and  Mortnd  Anatomy  at  Chnring-Cr  ons  Hospital  Medical  School. 

PATHOLOGY  AND  MORBID  ANATOMY.   Second  American,  from 

the  Third  and  Enlarged  Engli.sh  Edition     AVith  numerous  illu.strations  on  Wood.     In  on« 
very  handsome  octavo  volume  of  over  300  pages,  cloth,  $2  75       (Just  Ready.) 
This    usotul    and    convenient   manual    has    already 

nached  a  third  edition,  and  we  are  glad  to  find  that. 

al  hough  it  has  grown  somewhat  larger,  it  still  remains 


a  little  book,  and  wi;  are  inclined  to  forgive  the  increase 
in  size  on  account  of  the  valuable  additions  whicli  the 
author  has  made  both  to  the  printed  matter  and  to  the 
illustrations.  The  new  illustrations,  drawn  by  Mr.  Cei- 
lings from  preparations  by  Dr.  Green  himself,  are  verj' 
good,  and  the  care  and  trouble  expended  by  the  author 
in  the  preparation  of  this  edition  will  no  doubt  increase 
the  popularity  of  his  book,  great  though  it  already  is. — 
Tlie  London  Practitioner,  Feb.  1876. 


We  observe  that  the  whole  has  been  carefully  revised, 
that  a  considerable  addition  has  been  maile  to  the  illus- 
trations, and  that  much  new  matter  has  been  added. 
We  have  not  space  for  noting  each  of  the  additions  that 
have  been  made,  and  it  is  quite  unnecessary  lo  attempt 
iliis.  fir  a  work  which  has  already  gained  a  deservedly 
solid  reputation,  it  is  enough  to  say  that  it  has  been 
lirought  ilmroughly  up  to  the  knowledge  of  the  present 
day,  and  that  the  student  can  have  no  better  or  safer 
iuide  to  pathology  and  morbid  anatomy  tliau  Dr. 
Ijreen's  book. — Land.  Times  and  Gaz.,  Sept.  1875. 


GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated,  with  Notes  and  Additions,  by  Joseph 
Leiuy,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  cloth.     $■!  00. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in  itf 
Historical,  Pathological,  Etiological,  andTherapen 
tical  Relations.  In  two  large  and  handsome  ociav. 
volumes  of  nearly  1500  pages,  cloth.     $7  00. 

HOLLAND'S  MEDICAL  NOTE*  AND  EEFLjiC- 
TI0N3.     1  vol.  8vo.,  pp.  500,  cloth.     $3  60. 


LAYCOCK'S  LECTURES  ON  THE  PRINCIPLES 
AND  Methods  of  Medical  Observation  and  Re- 
search. For  the  use  of  advanced  students  and 
junior  practitioners.  In  one  very  neat  royal  12mc. 
volume,  cloth.    $1  00. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Condik, 
M    D.     1  vol.  8vo.,  pp.  600.  cloth.     *2  50. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN  ACUTB 
Diseases.  In  one  neat  octavo  volume,  of  320  pages, 
cloth.    !|l2  60. 


8 


T URGES  {OCTAVIUS),  M.D.  Cantab., 

Fellow  of  the  Royal  College  of  Physicians,  A-c.  A-c. 

AN  INTRODUCTION  TO  THE  STUDY  OF  CLINICAL  MED- 
ICINE. Being  a  Guide  to  the  Investigation  of  Disease,  for  the  Use  of  Students.  In  one 
handsome  12mo.  volume,  cloth,  ^1  25.      (Lately  Issued.) 


D 


AVIS  [NATHAN  S.), 

Prof,  of  Prinrdptes  and  Pranticc  of  Medicine,  etc.,  in  Chicago  3fed.  College. 

CLINICAL  LECTURES  ON  VARIOUS    IMPORTANT    DISEASES; 

being  a  collection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hos- 
pital, Chicago.  Edited  by  Frank  H.  Davis,  M.D.  Second  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.     Cloth,  $1  75.     (Lately  Issued.) 


OTOKES  [WILLIAM),  M.D..  D.C.L.,  F.R.S., 

'^  Regius  PriftHsor  of  Physic  in  the  Univ.  of  Dublin,  Ace. 

LECTURES  ON  FEYER,  delivered  in  the  Theatre  of  the  Meath  Hos- 
pital and  County  of  Dublin  Infirmary.  Edited  by  John  William  Moore,  M.D  ,  Assistant 
Physician  to  the  Cork  Street  Fever  Hospital.  In  one  neat  octavo  volume.  Cloth,  .■^2  00. 
(JXuw  Heady  ) 


HsNRY  C.  Lea's  Publications— (Practice  of  Medicine). 


15 


Tj^LINT  [AUSTIN],  M.D., 

«•  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N.  Y 

A   TREATISE    ON    THE    PRINCIPLES    AND    PRACTICE    OF 

MEDICINE  ;   designed  for  the  use  of  Students  and  Practitioners  of  Medicine.     Fourth 

edition,  revised  and  enlarged.    In  one  large  and  closely  printed  octavo  volume  of  about  1 100 

pages  ;  cloth,  $fi  00  ;  or  strongly  bound  in  leather,  with  raised  bands,  $7  00.     (Just  I.isiird.) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 

to  the  highest  position  as  a  complete  and  compendious  text-book  on  the  most  advanced  condition 

of  medical  science.     At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one  of  the 

cheapest  volumes  now  before  the  profession. 

dents  and  a  book  of  ready  reference  for  practilioneiR. 
The  fvirce  of  its  logic,  its  simple  and  pmciiral  teach- 
ing's, have  left  it  wiihout  a  rival  in  the  field  — A'.  Y. 
Mai   Record,  Sept.  1:"),  1874 

Flint's  Practice  of  M^idicine  has  become  so  fixed  in 
its  positional  an  Amoi-ican  textbook  that  little  need 
!  be  said  bpyond  thp  annoiincem'>nt  of  a  new  edition. 
It  may.  however,  be  pvonor  to  say  that  the  author 
■■■"■■■  r—--  -■■" — r.  v.-vv.  ..  .^  ev„ — V.  v,..^,  - —  I  ))^s  improved  the  occasion  to  introduce  the  latest 
hHtlliP  author  has  very  fairly  brought  up  Ins  mat  er  L.^„,,.il,^tio„s  of  medical  literature  together  with  the 
totbpleveloftheknowledeeof  the  present  duy.  The  ,.^,,,1,8  of  his  own  continued  clinical  observations 
work  h'ls  this  great  recommendation,  (hatitisinoue 
volunu,  and  ttierefore  will  not  he  so  terrifying  to  the 
student  as  the  bulky  volumes  which  several  of  our 
Euifli-^h  text-books  of  medicine  have  developed  into. 
—  British  and  Foreign  Med.-Chir.  Ri:v.,  Jan.  187." . 

It  is  of  course  unnecessary  tointrodlice  or  eulogize 
this  now  standard  treatise  All  the  colleges  recom- 
mend it  as  a  text-book,  and  there  are  few  libraries 
in  whicli  one  of  its  editions  is  not  to  be  found.  The 
present  edition  has  been  enlarged  and  revised  lo  bring 
it  up  to  the  author's  present  level  of  experience  and 
reading.  His  own  clinical  studies  and  the  latest  con- 
tributions to  medicil  literature  both  in  this  country 
and  in  Europe,  have  received  careful  attention,  so 
that  some  portions  have  been  entirely  rewritten,  and 
about  seventy  pages  of  new  matter  have  been  added. 
— Qtiicngo  Med.  Journ.,  June,  1873. 

Has  never  been  surpassed  as  a  text-book  for  stu- 


This  excfillent  treatise  on  medicine  lias  acquired 
for  itself  in  the  Hnited  .States  a  reputation  similar  to 
that  enioyed  in  England  by  the  admirable  lectures 
of  Sir  Thomas  Watson.  It  may  not  possess  the  same 
charm  of  style,  but  it  has  like  solidity,  the  fruit  of 
li'Ug  and  patient  observation,  and  presents  kindred 
moderation  and  pcleciicisra.  We  have  referred  to 
many  of  the  most  important  chapters,  and  find  the  re- 
spoken  of  in  the  preface  is  a  genuine  one,  and 


Not  so  extended  as  many  of  the  standard  works  on 
practice,  it  still  is  snfliciently  complete  for  all  ordi- 
nary reference,  and  we  do  not  know  of  a  more  con- 
venient work  for  the  busy  general  praclilioner. — 
Cincinnati  Lancet  and  Observer,  Juue,i;167.3. 

Prof.  Flint,  in  the  fourth  edition  of  liis  great  work, 
has  performed  a  labor  reflecting  much  credit  upon 
himself,  and  conferring  a  lasting  benefit  upon  the  pro- 
fession. The  whole  work  shows  evidence  of  thorough 
revision,  so  that  it  appears  like  a  new  book  wiitten 
expressly  for  the  times  For  thegeueral  practitioner 
and  student  of  medicine,  we  cannot  recommend  the 
book  in  too  strong  terms — N.  Y.  Med.  Jour.,  Sept.  '73. 

It  is  given  to  very  few  raeu  to  tread  iu  the  steps  of 
Austin  Flint,  whose  single  volume  on  medicine 
though  here  and  there  defective,  is  a  masterpiece  of 
lucid  condensation  and  of  general  grasp  of  an.enor 
mously  wide  subject  — Lond.  Practitioner,  Dec.  '73' 


■f>T  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE   MEDICINE    AND    KINDRED 

TOPICS.     In  one  very  handsome  royal  12mo.  volume.     Cloth,  $1  38.     (Just  Issued.) 

This  little  work  coniprisfs  a  number  of  e.-^says  written 
at  various  times  for  meilioal  journals  and  societies.  It  is 
iinueoessary  losay  aujrhtin  rejr.trd  to  the  stvlein  which 


they  are  written,' for  Dr.  Flint  is  familiar  as  a  house- 
hold word  to  the  profession.  His  name  i.s  a  !;uaranti'e 
thfit  the  subjects  are  treated  in  a  masterly  manner.  The 
fol  lowing  subjects  are  discussed :  Conservative  mc(Iicine, 
as  anplied  to  therapeutics  and  hygiene,  medicine  in  the 
past,  the  present,  and  the  future,  alimentation  in  dis- 
ease, tolerance  of  disease,  on  the  agency  of  the  mind  in 


etiology,  prophylaxis,  and  tlicrapcutics.  and  divine  de- 
sign, as  exemplified  in  the  natural  history  of  diseases. 
A  more  suggestive  collection  of  topics  it  woulil  be  difli- 
cult  to  conceive  The  essays  on  conservative  medicine 
arc  peculiarly  valuable.  The  author  in  these  lakes  a. 
very  common-sense  view  of  the  treatment  of  disease, 
and  shows  the  necessity  of  "conservinir"  to  the  fullest 
extent  the  strength  of  the  system  in  onler  to  devisp  the 
best  rcsultslrom  therj'.s  medicutrix  natiira:. — Peninsular ■ 
Mnl.  Journ  ,  Oct.  Is74. 


JJTA  TSON  (THOMAS),  M.  D.,  ^c. 

'^^  LECTURES     ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illustra- 
ations  by  Henrv  Hart.shornb,  M.D.,  Professor  of  Hygiene  in  the  University  of  Pennsylv. 
nia  In  two  large  and  handsome  8vo.  vols.  Cloth,  $9  00  ;  leather,  $11  00.  {Lately  Puhlislud.) 
.,  __...,i.,.;„„  ....^  f..r  HiunWtnl.     *i)npecialed.    that    it    is    scarcely    necessary    to    dt 


It  is  a  subject  for  congratulation  and  for  thankful 
ness  that  Sir  Thomas  Watson,  during  a  period  of  com- 
parative leisure,  after  a  long,  laborious,  and  most 
honorable  professional  career,  while  retaining  full 
possession  of  his  high  mental  faculties,  should  have 
employed  the  opportunity  to  submit  his  Lectures  to 
a  more  thorough  revision  than  was  possible  during 
The  earlier  and  busier  period  of  his  life.  Carefnlly 
nassingiu  review  some  of  the  most  intricate  and  im- 
portant pathological  and  practical  rjuestions,  the ro- 
Lltsof  hisclear  insight  and  his  calm  .tudgment  are 
now  recorded  for  the  benefit  of  mankind,  in  language 
which,  for  precision,  vigor,  and  classical  elegance,  has 
rarelvbeeu  equalled,  and  never  surpassed  The  le- 
'vtsion  has  evidently  been  most  carefully  done^nd 
the  results  appear  in  almost  every  page.-Brii.  Med. 
Journ.,  Oct.  1-t,  1871. 

The   lectures  are   so  well   known  and   so  justly 


appreciated,  that  it  is  scarcely  necessary  to  do 
more  than  call  attention  to  the  special  advantages 
of  the  last  over  previous  editions  The  author's 
rare  combination  of  great  scientific  altaiunients  com- 
bined with  wonderful  forensic  eloijuence  has  exerted 
extraordinary  influence  over  the  last  two  generutinus 
of  physicians.  His  clinical  descriptions  of  most  dis- 
eases have  never  been  equalled;  and  on  this  score 
at  least  his  work  will  live  long  in  the  fuluie.  The 
work  will  be  sought  by  all  who  appreciate  a  great 
book.— Jm^r  Journ.  of  Suphitograjihi/,  Ju\y,  1S72. 
Maturity  of  years,  extensive  observation,  profound 
research,  and  "yet  continuous  enthusiasm,  have  com- 
bined to  give  us  in  this  latest  edilii>n  a  m.>del  of  pro- 
fessional excellence  in  teaching  with  rare  beauty  in 
the  mode  of  cominunicalion.  but  this  ch'ssic  need* 
no  eulogium  of  ours.— OViifajr')  3/^(/.  Journ.,  July, 
1872 


D 


TJNGLISON,  FORBES  TWEEDIE,  AND  CONOLLY. 

TTTF  rvCLOP.EDIA  OF   PRACTICAL  MEDICINE:   comprising 

THE  ^^'^^yVaH,Ve\nd  Treatment  of  Diseases,  Materia  Medica  and  Therapeutics, 
Treatises  «V'nrd  Children  Cdic.Vjurisprude;ce,  Ac.  Ac.  In  four  large  super-royal 
SvT^oluIr^f  32^4  So'^Ue-cied  pages,'strongly  and  handsomely  bound  in  leather. 
$15;  cloth,  $11. 


16 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


B 


RISTO  iri?  [JOHN  SYER),  M.D.,  F.R.C.P.     (Nearly  Ready.) 

Phyn  eian  and  Joint  Lecturer  on  Medicine,  St.  Thnmmt'n  Hnnjiital. 

A  MA^'Uj^L  on  the  practice  of  MEDICIXE.    Edited,  with 

Additions,  by  Jawes  H.  Hutchinson,  M.D.,  Physician  to  tba  Penna    Hospital.     In  one 
band&ome  octavo  volume. 


Tf  OTHER  GILL'S  PRACTITIONER'S  HANDBOOK  OF   TREATMENT. 

-*■  In  one  handsome  octavo  volume.      (In 2i>'fyaratiun  fur  early  j)ublicatio7i.) 


H' 


ARTSHORNE  [HENRY),  M.I)., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

ESSENTIALS  OP  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 

CINE.     A  bandy-book  for  Students  and  Practitioners.     Fourth  edition,  revised  and  im- 
proved.    With  about  one  hundred  i!lu.«trations.     In  one  handsome  royal  ]2mo    volume, 
of  about  550  pages,  cloth,  $2  63;  half  bound,  $2  88.      (Just  Issued.) 
The  thorough  manner  in  which  the  author  has  labored  to  fully  represent  in  this  favorite  hand- 
book the  most  advanced  condition  of  practical  medicine  is  shown  by  the  fact  that  the  present 
edition  contains  more  than  260  additions,  representing  the  investigations  of  172  authors  not  re- 
ferred to  in  previous  editions.     Notwithstanding  an  enlargement  of  the  page,  the  size  has  been 
increased  by  sixty  pages.     A  number  of  illustrations  have  been  introduced  which  it  is  hoped 
will  facilitate  the  comprehension  of  details  by  the  reader,  and  no  effort  has  been  spared  to  make 
the  volume  worthy  a  continuance  of  the  very  great  favor  with  which  it  has  hitherto  loeen  received. 
The  woik  is  brought  fully  up  with  al!  the  recent  J      Without  dilnbt  the  best  hook  of  thekiad  published 
advances  in  medicine,  is  admirably  condenfed,  and     in  the  English  language. — Ht.  Louis  Med.  and  Surg. 


yet  -sufficiently  explicit  for  all  the  purposes  intended, 
thus  making  it  by  far  the  best  work  of  its  character 
ever  publibhed. —Cmein?i«<i  Clinic,  Oct.  24,  1874. 


Journ  ,  ^'ov.  1874. 
Asa  handbook,  which  clearly  seto  forth  the  essbn- 

TIAI..S  of  the  PRINCIPLES  AND  PRACTICE  OP  .MEDICIXE,  We 

We  have  already  had  occasion  to  notice  the  previ-    ^^  no'  know  of  its  equal.-  Va.  Med.  Monthly. 
ous  editions  of  thi.K  work.     It  is  excellent  of  its  kind.  1      As  a   brief,  condensed,  bnt  comprehensive  hund- 
Tlie  author  has  given  a  very  careful  revision,  in  view     book,  it  cannot  be  iirproved  upon. — Chicago  Mtd. 
of  the  rapid  p^ogre^s  of  medical  science.— >A'.  Y.  Mtd.  '  Examiner,  Kov.  15,  1S74. 
Journ.,  Kov.  1S74.  I 


OArY{F.W.),M.D.,F.R.S., 

Senior  Asst.  Physician  to  and  Lecturer  on  Physiology,  at  Guy's  Hospital,  &e. 

A  TREATISE  ON  THE    FUNCTION  OF   DIGESTION;  its  Disor- 

ders  and  their  Treatment.     From  the  second  London  edition.     In  one  handsome  volume, 
small  octavo,  cloth,  $2  00. 

>  T  THE  SA  ME  A  UTHOR.      (Just  Issued. ) 

A  TREATISE  ON  FOOD  AND  DIETETICS,  PHYSIOLOGI- 
CALLY AND  THERAPEUTICALLI  CONSIDERED.  In  one  handsome  octavo  volume 
of  nearly  600  pages,  cloth,  $4  76. 

which  shows  that  the  author  is  an  extensive  reader  and 
has  judiciously  arranged  the  numerous  facts  and  theo- 
ries, toiielher  with  the  most  striking  experiments  and 
the  deductions  drawn  therefrom.  It  seems  to  u.s  that 
he  has  truly  conferred  u. ureal  henetit  upoji  all  interested 
in  the  .-iubjcct-mittler  of  his  work,  and  that  noljody  will 
study  its  paiies  without  having  derived  vaUiabie  instruc- 
tion therefrom,  and  without  considering  it  not  only  use- 
ful, but  next  to  indispensable. —  Amer.  Journ.  of 
Phurmucy,  Aug.  1874. 


The  present  book  is  a  result  of  hi.-i  work  in  this  direc- 
tion, and  is  well  calculated  to  do  credit  to  his  perseve- 
rance in  collectin>;  facts,  and  his  judgment  in  arranging 
them  in  an  entertaining,  as  well  as  a  practical  form.  l1 
is  but  rarely  that  we  have  had  offered  us  ."o  much 
practical  information  iu  so  agreeable  a  manner  as  is 
done  by  Dr.  I'avy  iu  the  present  instance.— i\'cio  Jitme- 
difts,  July,  lb74. 

No  modern  treatise  on  this  subject,  having  existed  in 
the  English  language,  Dr.  Pavys  work  supplies  a  want 
which  has  been  very  seriously  felt,  and  iu  a  manner 


0 


HAMBERS  [T.  K.),  M.D., 

Consulting  Physician  to  St.  Mary's  Hospital,  London,  &c. 

A  MANUAL  OF  DIET  AND  REGIMEN  IN  HEALTH  AND  SICK- 


NESS.  In  one  handsome  octavo  volume. 
In  compiliugthis  small  but  comprehensive  manual  | 
Dr.  Chambers  has  laid  the  profession  under  a  debt 
of  gratilude  to  him.  He  writes  ou  the  subject  like 
one  who  has  given  his  mind  to  it,  and  theretore  is 
r^'  u  '°  ^Pe^k  with  authority.  As  a  pioneer,  Dr 
Chambers  deserves  much  credit ;  he  hasopeued  up  a 


Cloth.  $2  75.  {Now  Ready.) 
new  field  of  which  others  will  no  doubt  avail  them- 
selves. Taken  altogether,  this  work  is  one  which 
gives,  in  an  agreeable  form,  much  valuable  informa- 
tion on  a  most  important  subject,  and  ought  to  have 
a  large  sale  both  in  the  profession  and  out  of  it. — 
London  Med.  Record,  May  19,  1875. 


_gr  THE  SAME  AUTHOR.     (Lately  Published.) 

RATIYE  MEDICINE.   An  Harveian  Annual  Oration. 

Two  Sequels.     In  one  very  handsome  volume,  small  12mo.,  cloth,  $1  00. 


With 


F 


'JX  (WILSON),  M.D., 

Holme  Prof,  of  Clinical  Med..  University  Coll.,  London. 

THE  DISEASES  OF  THE  STOMACH:  Being  the  Third  Edition  of 

the  "Diagnosis  and  Treatment  of  the  Varieties  of  Dyspepsia."     Revised  and  Enlarged. 
With  illustrations.     In  one  handsome  octavo  volume,  cloth,  $2  00.     (Jxist  Issued.) 


Henry  C.  Lea's  Publications— (Z)iseases  of  the  Chesl,  &c).        17 


PLINT  [AUSTIN),  M.D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Belle.vue  Hogpital  Med   College  If    X. 

A  PRACTICAL  TREATISE  OX  THE  DIACxNOSIS,  PATHOLOGY, 

AND  TKEATMENT  OP  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 
edition.     In  one  octavo  volume  of  560  pages,  with  a  plate,  cloth,  $4. 

.  ^'■•^''°'*^'"'®S''l'ffl«^l' subject  for  his  researches,  ;  and  clearest  practical  treatise  on  those  snbiects,  and 
and  has  shown  remarkable  powers  of  observation  should  be  in  the  hands  of  all  practitioners  Hud  stn- 
ana  reflection  as  well  as  e;reat  industry,  in  his  treat-  i  tents.  It  is  a  credit  to  American  medical  literatare. 
ment  ot  it.     His  book  musi  be  considered  the  fullest  I  —Amer.  Journ.  of  the  Med.  Sciences,  July,  1860. 

^T  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  OX  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 

Dr.  Flint's  treatise  is  one  of  the  most  trustworthy  i  sncy  to  over-refinement  and  unnecessary  minnteneps 
gmdes  wliich  we  can  consult.  The  atyle  is  clear  and  '  tvhich  characterizes  many  works  on  the  same  Bub- 
distinct,  and  is  also  concise,  being  free  from  that  tend-  iect.—Dtiblin  Medical  Press,  Feb.  6,  1867. 

J^r  THE  SAME  AUTHOR.     (Ju»f  Rmdy.) 

PHTHLSIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND  COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT, AND  PHYSICAL  DIAGNOSIS  :  in  a  series  of  Cliniciil  Studies.  By  Austi.v 
Flint,  M  D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  IKspital  Med. 
College,  New  Y'ork.  In  one  handsome  octavo  volume  :  $o  50. 
This  volume,  containing  the  results  of  the  author's  extended  ohservation  and  experience  on  a 
subject  of  prime  importance,  cannot  but  have  a  claim  upon  the  attention  of  every  practitioner. 

This  hook  contains  an  analysis,  in  the  author's  hicirt 
style,  of  the  notes  which  he  has  made  in  several  hun- 
dred rases  in  hospital  and  pvivato  practice.     We  com 


mend  the  hook  to  the  perusal  of  all  interested  in  the 
study  nf  this  disease. — Boston  Med.  and  Surg  Journal, 
Feb  10,  1876. 

The  name  of  the  author  is  a  sufficient  {rnarantee  that 
this  book  is  of  practical  value  to  both  studeut  and  i]rac.- 


titioner.  While  the  author  takes  issue  with  many  of  the 
leadinf:  minds  of  the  day  on  important  qneslion.a  arising 
in  the  study  of  phthisis,  the  stron;;  testimony  of  expe- 
rience and  authority  will  have  great  weinht  with  the 
seeker  after  truth.  As  the  result  of  clinicnl  study,  the 
work  is  unequalled. — St. Louis  Med.atul  Suri;  Journal, 
March,  1876. 


DF   THE   SAME   AUTHOR.     (Now  Rfxidy.) 

A  MANUAL   OF  PERCUSSION  AND    AUSCULTATION;    of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.     In 
one  handsome  royal  ]2mo.  volume:  cloth,  §1   75. 
In  this  little  work  the  object  of  the  author  has  been  to  present  in  a  clear  and  compact  form 
the  existing  condition   of  physical  exploration,  showing  the  manner  of  conducting  it  and  the 
diagnostic  value  of  the  several  signs  thereby  elicited. 

This  manual,  from  so  experienced  a  pen  as  that  I  dent  or  practitioner  who  is  somewhat  rusty  on  the 
of  its  author,  coald  not  be  otherwise  than  concise  "physical  signs"'  it  will  prove  just  the  hook  he 
cleaj-,  and  practical.     It  is  allthe.se,  and  to  the  stu-  |  wants. — Med.  and  Surg.  Reporter.  Aiiir   1  !•,  l>>7i;. 


'PULLER  [HENRY  WILLIAM),  3L  D., 

•^  Physician  to  St.  George's  Hospital,  London. 

ON  DISEASES  OF  THE    LUNGS   AND    AIR-PASSAGES.    Their 

Pathology,  Physical  Diagnosis,  Symptoms,  and  Treatment.     From  the  second  and  revised 
English  edition.     In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $3  50. 


W' 


ILLIAMS  [C.  J.  B.),  M.D., 

Senior  Consulting  Physician  to  the  Hospital  for  Consumption,  Brompton. 

PULMONARY  CONSUMPTION;  Its  Nature,  Varieties,  and  Treat- 
ment. With  an  Analysis  of  One  Thousand  Cases  to  exemplify  its  duration.  In  one  neat 
octavo  volume  of  about  350  pages,  cloth,  $2  50.      {Lately  Fublisked.) 


He  can  still  speak  from  a  more  enormous  experi- 
ence, and  a  closer  study  of  the  morbid  jirocesses  in- 
volved iu  tuberculosis,  than  most  living  men.  He 
owed  it  to  himself,  and  to  the  importance  of  the  sub- 
ject, to  embody  his  views  in  a  separate  work,  and 
we  are  glad  that  he   has  accomplished  this  duty. 


After  all,  the  grand  teaching  which  Dr  Williams  ha" 
for  the  profession  is  to  be  found  in  his  therap.'Utical 
chapters,  and  in  the  history  of  individual  cases  ex- 
:ended,  by  dint  of  care,  over  ten,  twenty,  thirty,  and 
9ven  forty  years. — London  Lancet,  Oct.  21,  lt>71. 


LA  ROCHE  ON  PNEUMONIA.     1  vol.  8vo.,  cloth,  |  the  second  and  enlarged  London  edition.    With  il- 

of  500  pages      Price.$3  00.  lustrations  on  wood      In   one   hand^omi   octavo 

SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE-  |  '->'«""'  of  about  .WO  pages:  cloth,  fl  2.'.. 

MEDIABLE  STAGES.     1  vol.  8vo.,  pp.  2.^.     i^S  2fi.     WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 

LECTURES  ON  THE  DISEASES  OF  THE  STOMACH.  I  GREAT  VESSELS.     Third  American   ediUoa.    la 

With  an  Introduction  on  its  Anatomy  and  I'bysio-  ;  1  vol.  8vo..  420  pp.,  cloth.    $3  00. 

logy.     By  VV1H.1A.M  BKi.vroN,M.D.,  F.R,  S      From] 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


DOBERTS  (  WILLIAM),  M.  D.. 

•*■•'  Lecturer  on  Medicine  in  the  Manchester  Hchnnl  of  Medicine,  &c. 

A  PRACTICAL  TREATISE    ON  URINARY  AND    RENAL   DIS- 

EASES,  including  Urinary  Deposits.    Illustratefl  by  numerous  cases  and  engravings.    Sec- 
ond American,  from  the  Second  Revised  and   Enlarged  London  Edition.      In    one  large 
and  handsome  octavo  volume  of  61fi  pages,  with  a   colored  plate  ;   cloth,  $4  50.      (Lately 
Puhlished.) 
The  author  has  subjected  this  work  to  a  very  thorough  revision,  and  has  sought  to  embody  in 
it  the  results  of  the  latest  e.xperience  and  investigations.     Although  every  effort  has  been  made 
to  keep  it  within  the  limits  of  its  former  size,  it  has  been  enlarged  by  a  hundred  pages,  many 
new  wood-cuts  have  been  introduced,  and  nlso  a  colored  plate  representing  the  appearance  of  the 
ditferent  varieties  of  urine,  while  the  price  has  been  retained  at  the  former  very  moderate  rate. 


Tliff  plan,  it  will  thus  be  sefQ.  Sk  very  cnmplfie, 
an!  tlie  manner  in  which  it  has  been  curried  out  is 
in  the  hi£;hest  degree  satisfactury.  The  characters 
of  the  different  depcsit.s  are  very  well  described,  and 
the  microscopic  appearances  they  present  are  illu! 


diseases  we  have  examined  It  is  peculiarly  adapted 
to  the  wants  of  the  majority  of  American  practition- 
ers from  its  clearness  and  simple  announcement  of  the 
facts  in  relation  to  diagnosis  and  treatment  of  urinary 
disorders,  and  contains  in  condensed  form  the  in  ve.s ti- 


trated by  numerous  well  executed  engravings  It  i  gallons  of  Bence  Jones,  Bird,  Beale,  Hassall,  Prout, 
only  remains  to  us  to  strongly  recommend  to  our  1  and  a  host  of  other  well-known  writers  upon  this  sub- 
readers  Dr.  Roberts's  work,  as  coniaining  an  admira-  '  ject.  The  characters  of  urine,  physiological  and  pa- 
ble  n'fcicini  of  the  present  state  of  knowledge  of  uii-  thological.  as  indicated  to  the  naked  evens  well  as  by 
nary  diseases,  and  as  a  safe  and  reliable  guide  to  the  microscopical  and  chemical  investigations,  are  con- 
clinical  observer. — Edin.  Med.  Jnur.  ,  cisely  represented  both  by  description  and  by  well 

The  mostcompleteand  practical  treati.se  upon  renal    executed  eagi&viags.— Cincinnati  Journ.  of  Med_ 


B 


ASH  AM  (W.R.),  M.D., 

Se.nii>r  Phyxician  to  the  Wextmin.ifer  ffonjiitnt,  <tc. 

RENAL  DISEASES:  a  Clinical  Guide  to  their  Diagnosis  and  Treatment. 

With  illustrations.     In  one  neat  royal  12mo.  volume  of  304  pages,  cloth,  $2  00. 


The  chapters  on  diagnosis  and  treatment  are  very 
good,  and  the  student  and  young  practitioner  will 
Bnd  them  full  of  valuablepractical  hints.  The  third 
part,  on  the  urine,  is  excellent,  and  we  cordially 
recommend  its  perusal.  The  author  has  arranged 
his  matter  in  a  somewhat  novel,  and,  we  think,  use- 
ful form.  Here  everything  can  be  easily  found,  and, 
what  is  more  important,  easily  read,  for  all  the  dry 


details  of  larger  books  here  acquire  a  new  interest 
t'rom  the  author's  arrangement.  This  part  of  (lie 
^)ook  is  full  of  good  work. — Brit,  and  For.  Medico- 
Ihirurgical  Review,  July,  1870. 

The  easy  descriptions  and  compact  modes  of  state- 
ment reiider  the  book  pleasing  and  convenient. — Am. 
Journ.  Med.  Sciences,  July,  1870. 


TNCOLN  [D.  F.).  M.D., 

'  Phvfiician  to  the  Department  of  Nervous  Diseases,  Bo.^ton  Dispensary. 

ELECTRO  THERAPEUTICS  ;  4  Concise  Manual  of  Medical  Electri- 


city.  In  one  very  neat  royal  12mo.  volume 
The  work  is  convenient  in  size,  its  descriptions  of 
metliods  and  appliances  are  sufficiently  complete  for 
the  general  practitioner,  and  the  chapters  on  lilectro- 
physiology  and  diagnosis  are  well  written  and  read- 
able. For  those  who  wish  a  handy-book  of  directions 
for  the  employment  of  galvanism  in  medicine,  this 
will  serre  as  a  very  good  and  reliable  guide. — Nkio 
Remedies,  Oct.  1874. 

It  is  a  well  written  work,  and  calculated  to  meet 
the  demands  of  the  busy  practitioner.  It  contains 
the  latest  researches  in  this  important  branch  of  med- 
icine.—  Pe.ninstdar  Journ.  of  Med.,  Oct.  1S74. 

Eminently  practical  in  character.  It  will  amply 
repay  anv  one  for  a  careful  perusal. — Leavenworth 
Med.  Herald,  Oct.  1874. 


,  cloth,  with  illustrations,  $1  50.  (Just  Issued.) 
This  little  book  is,  consideiiug  its  size,  one  of  the 
very  best  of  the  English  treatises  on  its  subject  that 
has  come  to  our  notice,  possessing,  among  others,  tlse 
rare  merit  of  dealing  avowedly  and  actually  with 
principles,  mainly,  ratherthan  with  practical  details, 
tliereby  supplying  a  real  want,  instead  of  helping 
merely  to  flood  the  literary  market.  l)r.  Lincoln  s 
style  is  usually  remarkably  clear,  and  the  whole 
book  is  readable  and  interesting. — Boston  Med.  and 
fSurg.  Journ.,  July  23,  1874. 

We  have  here  in  a  small  compass  a  great  deal  of 
valunble  information  upon  the  subject  of  Medical 
Electricity. — Canada  Med.  and  Surg.  Journ  ,  Nov. 
1874. 


TEE  {HENRY), 

Prof,  of  Surgery  at  the  Royal  College  of  Surgeons  of  England,  etc. 

LECTURES  ON  SYPHILIS  AND  ON  SOME  FORMS  OF  LOCAL 

DISEASE  AFFECTING  PRINCIPALLY  THE  ORGANS  OF  GENERATION.     In  one 

handsome  octavo  volume  :  cloth;  $2  25.      (Now  Ready.) 


To  the  fultilment  of  his  task  he  has  applied  a  wide 
and  philosophical  rom]irehension  of  the  general  and 
special  patholoiry  of  the  subject,  one  which  his  own  ex- 
tended personal  experience  gives  him  a  strong  right  to 
handle  A  perusal  of  it  cannot  fail  to  interest  the  reader, 
who  will  find  in  it  reports  of  many  interesting  cases  and 
experiments,  together  with  much  suggestive  philosoph- 
ical discussion — not  to  say  quotations  from  the  poets — 
an  embellishment  rarely,  we  believe,  accorded  this  par- 
ticular subject. — Lo-ndnn  Practitioner,  .March,  1876. 

The  work  ,is  valuable,  as  it  treats  quite  fully  of  sub- 
jects which  are  not  dwelt  upon  in  the  systematic  works 


of  other  Eniilish  authors  of  the  present  day,  as  the  inoc- 
ulaliilir.y  of  .syphilitic  lilooU:  the  conditions  under  which 
the  secretions  of  primary  and  secondary  syphilitic  man- 
ifestations maybe  inoculated  naturally  or  artificially ; 
the  morbid  processes  produced  by  such  inoculation :  the 
modifications  of  these  processes  in  patients  previously 
syphilitic:  primary  and  .secondary  syphilitic  diseases  of 
the  mucous  membranes  and  their  liability  to  commu- 
nii^Tte  constitutional  syphilis,  etc.  The  book  is  full  of 
clinical  material  illustrating  these  topics,  original  or 
quoted. — Archives  of  Dermatology,  April,  1S70. 


DIPHTHERIA  ;  its  Nature  and  Treat  nent,  with  an 
account  of  the  History  of  its  Prevalence  in  vari- 
ous Countries.  By  D  D.  Slade,  M.  D.  Second  and 
revised  edition.  In  one  neat  roval  12mo.  volume, 
cloth,  ■fil  2.). 

LECTHRES  ON  THE  STUDY  OF  FEVER.  By  A. 
Hudson-,  M.l)..  M.R.I.A.,  Physician  to  the  Meath 
Hospital.     In  one  vol.  Svo.,  cloih,  -$2  50.  i 


A  TREATISE  ON  FEVER.  By  Robkrt  D.  Ltons, 
K  C  C.  In  one  octavo  volume  of  362  pages,  cloth, 
$2  2o. 

CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  UISOKDERS  BvC.  Hanofiei.o  Jonrs, 
M.D.,  Physician  to  St.  Mary's  Hospital,  &c.  Sec- 
ond American  Edition.  In  one  htndsome  octavo 
volume  of  348  pages,  cloth,  $3  2.5. 


Henry  C.  Lea's  Publications — ( Venereal  Diseases^  (Cc). 


19 


f>UMSTEAD  [FREEMAN  J.),  M.D., 

*-'        Professor  of  Venereal  Diseases  at  the  Col.  of  Phys  and  Surg.,  New  York.  Ac. 

THE    PATHOLOGY   AND   TREATMENT   OF   VENEREAL   DIS- 

EASES.     Including  the  results  of  recent  investigations  upon  the  subject.     Third  edition, 

revised  and  enlarged,  with  illustrations.     In  one  large  and  handsome  octavo  volume  of 

over  700  pages,  cloth,  $5  00  ;  leather,  $6  00. 

In  preparing  this  standard  work  again  for  the  press,  the  author  has  subjected  it  to  a  very 

thorough  revision.    Many  portions  have  been  rewritten,  and  much  new  matter  added,  in  order  to 

bring  it  completely  on  a  level  with  the  most  advanced  condition  of  syphilography,  but  by  careful 

compression  of  the  text  of  previous  editions,  the  work  has  been  increased  by  only  si.xty-four  pages. 

The  labor  thus  bestowed  upon  it,  it  is  hoped,  will  insure  for  it  a  continuance  of  its  position  as  a 

complete  arid  trustworthy  guide  for  the  practitioner. 


It  is  the  most  coinpletebook  with  which  we  are  ac- 
qnainted  iu  the  language.  The  latest  views  of  the 
best  authorities  are  put  forward,  and  the  information 
Is  well  arranged — a  great  point  for  tlie  student,  and 
still  more  for  the  practitioner.  The  subjects  of  vis- 
ceral syphilis,  syphilitic  affections  of  the  eyes,  and 
the  treatment  of -syphWis  by  repeated  inoculalious.  are 
very  fully  discussed. — London  Lancet,  Jan.  7,  1871. 

Dr.  Bumstead's  work  is  already  so  universally 
fcnown  as  the  best  treatise  in  the  English  laugu:tge  on 
venereal  diseases,  that  it  may  seem  almost  .superflu- 
ous to  say  niore  of  it  than  that  a  new  edition  has  been 

Issued.     But  the  author's  industry  has  rendered  this  |  Journal,  March,  1871 
new  edition  virtually  a  new  work,  and  so  merits  as  ' 

pULLERIER  [A.),  ai7d 

«-^         Surgeon  to  the  Hdpital  du  Midi. 


much  special  commendation  as  if  it«  predecessors  had 
not  been  published.  As  a  thoroughly  prni-tical  book 
on  a  class  of  diseases  which  form  a  laiffe  »hare  of 
nearly  every  physician's  practice,  the  volume  before 
us  is  bv  far  the  best  of  which  we  have  knowledge. — 
N.  Y.  Medical  Gazette.  Jan.  28,  1871. 

It  is  rare  in  the  history  of  medicine  to  find  any  one 
book  which  contains  all  that  a  practitioner  needs  to 
know;  while  the  pos.^essor  of  "Burastead  on  Vene- 
real" lias  no  occasion  to  look  outside  of  its  covers  for 
anything  practical  connected  with  (he  diagnosis,  his- 
tory, or  treatment  of  these  atfections. — N.  Y  Medical 


T? UMSTEA D  ( FR EEMA N  J.), 

-*--'        ProfrJisorof  Venereal  Diseases  in  the  Oollegeof 
Phy.simans  and  Surgtons,  A'.  Y 

AN  ATLAS  OF  VENEREAL  DISEASES.     Translated  and  Edited  hy 

Freeman  J.  Bumstead.     In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  cloth,  $17  00  ;   also,  in  five  parts,  stout  wrappers  for  mailing,  at  $3 
per  part. 
Anticipating  a  very  large  sale  for  this  work,  it  is  ofi'ered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prac- 
tice.    Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay. 
A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


We  wish  foronce  that  our  province  was  not  restrict- 
ed to  methods  of  treatment,  that  we  might  say  some- 
thing of  the  exquisite  colored  plates  in  this  volume. 
— London  Practitioner,  May,  1869. 

As  a  whole,  it  teaches  all  that  can  be  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
13,  186S. 

.Superior  to  anything  of  the  kind  ever  before  issued 
on  this  continent.— CaJiarfa  Med.  Journal,  March,  'ti9. 

The  practitioner  who  desires  to  under.stand  this 
branch  of  medicine  thoroughly  should  obtain  this, 
the  most  complete  and  best  work  ever  published.— 
Dominion  Med.  Journal,  May,  1869. 

This  is  a  work  of  master  hands  on  both  sides.  M. 
CuUerier  is  scarcely  second  to,  we  think  we  may  truly 
say  is  a  peer  of  the  illustrious  and  venerable  Kicord, 
while  in  this  country  we  do  not  hesitate  to  say  that 
Dr.  Bumstead,  as  an  authority,  is  without  a  rival 
Assuringour  readers  that  these  illustrations  tell  the 
wholi?  history  of  venereal  disease,  from  its  inception 
to  its  end,  we  do  not  know  a  single  medical  work, 


which  for  its  kind  is  more  nec«*.v(frj/ for  them  to  have. 
—Calif  trnia  Med.  Gazette,  March,  1S69. 

The  most  splendidly  illustrated  work  in  the  lan- 
.{uage,  and  in  our  opinion  far  more  useful  than  th« 
f  reach  original. — Am.Journ.  Med.  Sciences,  Jan. '69. 

The  fifth  and  concluding  number  of  this  magnificeat 
work  has  reached  us,  and  we  have  uo  he^itati<>n  in 
saying  that  its  illustrations  surpass  those  of  pr«vione 
numbers.— fio*ion  Med.  and  Surg.  Journal,  Jan.  14, 
lSb.9. 

Other  writers  besides  M.  CuUerier  have  given  as  a 
good  account  of  the  diseases  of  which  he  treats,  but 
uo  one  has  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  diseases.  There  i*, 
however,  an  additional  interest  and  value  possessed 
by  the  volume  before  us  ;  forit  is  an  American  reprint 
and  translation  of  M.  Culleriei's  work,  with  inci- 
dental remaiksby  one  of  the  mosi  eminent  American 
syphilographers,  Mr.  Bumstead. —  firii.  and  For. 
Medico-Chit .  Review,  July,  1869. 


fpLL  (BERKELEY), 

Surgeon  to  the  Lock  Hospital,  London. 

ON  SYPHILIS  AND  LOCAL 

one  handsome  octavo  volume  ;  cloth,  $3 
Bringing,  as  it  does,  the  entire  literature  of  the  dis- 
ease down  to  the  present  day,  and  giving  with  great 
ability  the  results  of  modern  research,  it  is  in  every 
respect  a  most  desirable  work,  and  one  which  should 
Rnd  a  place  in  the  library  of  every  surgeon.— Co^i- 
f  trnia  Med.  Gazette,  June,  1869. 

Considering  the  scope  of  the  book  and  the  carefal 
attention  to  the  manifold  aspects  and  details  of  its 
subject,  it  is  wonderfully  concise  All  these  qualities 
render  it  an  especially  valuable  book  to  the  beginner, 


CONTAGIOUS  DISORDERS.    In 

25. 

I  to  whom  we  would  most  earnestly  recommend  Its 
I  study;  while  il  is  no  less  useful  to  the  practitioner.— 
St.  Louis  Med.  and  Surg.  Journal,  May,  1869. 

The  most  convenient  and  ready  book  of  reference 
I  we  have  met  with.— iV.  Y.  Med.  Record,  May  1, 1869. 

Most  admirably  arranged  for  both  student  and  prac- 
titioner, no  other  work  on  the  subject  equals  it  ;  it  U 
more  simple,  more  easily  Madied.— Buffalo  Med.  and 
Surg.  Journal,  March,  1869. 


z 


ETSSL  (H.),  M.D.  ^    ^      m 

A  COMPLETE  TREATISE  ON  VENEREAL  DISEASES.  Trans- 
lated from  the  Second  Etil.irged  German  Edition,  by  Frederic  R.  Stukg.s,  M.D.  In  one 
octavo  volume,  with  illustrations.     {Preparmg.) 


20 


Henry  C.  Lea's  Pubj,ioation8 — (Diseases  of  the  Skin). 


pox  [TILBURY). 
EPITOME   OF 

{Frepariiig.) 


SKIX    DISEASES.     In   one  handsome  vol.    ISrao. 


ffTTILSON  ( ERA SMUS),  F.R.S. 

ON  DISEASES  OF  THE  SKIX.     With  Illustrations  on  wood.    Sev- 

enth  American,  from  the  sixth  and  enlarged  English  edition.     In  one  large  octavo  volume 
of  over  800  pageg,  $5. 

A  SERIES   OF   PLATES   ILLUSTRATING  "WILSON   ON   DIS- 

EASES  OF  THE  SKIN;"  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  diseise,  most  of 
them  the  size  of  nature.     Price,  in  extra  cloth,  $5  50. 
Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.     Cloth,  $10. 

No  one  treating  skin  diseases  Khould  be  without  (  ind  acceptable  belp.    Mr.  Wilson  has  long  been  held 

is  high  authority  in  this  department  of  medicine,  and 
his  book  on  diseases  of  the  skin  has  long  been  r«- 
{arded  as  one  of  the  best  text-books  extant  on  the 
subjpct.  The  present  edition  is  carefully  preparfd, 
ind  brought  up  in  its  revision  to  the  prehent  time.  In 


-Canndn  Lancet. 


a  copy  of  this  standard  work. 

We  can  safely  recommend  it  to  the  profession  ar 
the  best  work  on  the  subject  now  in  existence  ii 
the  English  language. — Me.dico.1  Times  and  Gazette 

Mr.  Wilson's  volume  is  an  excellent  digest  of  th« 
actual  amount  of  knowledge  of  cutaneous  diseases 
It  include';  almost  every  fact  oropiniou  ofimportanct 
connected  with  the  anatomy  and  pathology  of  th< 
skin. — Britinh  and  Foreign  Medical  Review. 

Such  a  work  as  the  one  before  ua  Is  a  most  capital 


his  edition  we  have  also  included  the  beautiful  series 
>f  plates  illustrative  of  the  text,  and  in  the  last  edi- 
•ion  published  separately.  There  are  twenty  of  these 
plates,  nearly  all  of  them  colored  to  nature,  and  ex- 
hibiting with  great  fidelity  the  various  groups  of 
diseases. — Ginoinnati  Lancet. 


B 


Y  THE  SAME  AUTHOR. 


THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

BASES  OP  THE  SKIN.    In  One  very  handsome  royal  12mo.  volume.   $3  50. 


Jf^ELIGAN  [J.  MOORE),  M.D.,  31. R.I. A. 

ATLAS   OF  CUTANEOUS  DISEASES.      In  one  beautiful  quarto 

volume,  with  exquisitely  colored  plates,  &c.,  presenting  about  one  hundred  varieties  oi 

"' Cloth,  $5  50. 

to  which  the  particular  case  may  belong.  While 
.coking  over  the  "Atlas"  we  have  been  induced  t  o 
ixamine  also  the  "Practical  Treatise.'"  and  we  are 


disease 
The  diagnosis  of  eruptive  disease,  however,  under 
aU  circumstances,  is  very  difflcult.  Nevertheless, 
Dr.  Neligau  has  certainly,  "as  far  as  possible,''  given 
a  faithUU  and  accurate  representation  of  this  class  of 
disea>es,  and  there  can  be  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 


Inclined  to  consider  it  a  very  snperlor  woru,  coll; 
bining  accurate  verbal  description  with  sound  views 
of  the  pathology  and  treatment  of  eruptive  diseases. 
—  Olasgow  Med.  Journal. 


J^ILLIER  (THOMAS),  31. D., 

Physician  to  the  Skin  Department  of  University  College  Hospital,  &o. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  American  Edition.     In  one  royal  12mo.  volume  of  358  pp.     With  Illustrationz. 
Cloth,  $2  25. 

We  can  conscientiously  recommend  it  to  the  stu- 
dent;  the  style  is  clear  and  pleasant  to  read,  the 
matter  is  good,  and  the  descriptions  of  disease,  with 
the  modes  of  treatment  recommended,  are  frequently 
Illustrated  with  well -recorded  cases. — London  Med 
Times  and  Gazette,  April  1,  1865. 


It  is  a  concise,  plain,  practical  treatise  on  the  vari- 
ous diseases  of  the  skin  ;  just  such  a  work,  indeed, 
as  was  much  needed,  both  by  medical  students  and 
practitioners.  —  Chicago  Medical  Examiner,  M&y, 
1865. 


ANDERSON  [McCALL),  3I.D., 

■^  Physician  to  the  Dispensary  for  Skin  Diseases,  Glasgow,  &c. 

ON  THE  TREATMENT  OF  DISEASES  OF  THE  SKIN.     With  an 

Analysis  of  Eleven  Thousand  Consecutive  Cases.  In  one  vol.  8vo.   $1.   (^Lately  Published  ) 

^MITH [EUSTA CE),  M.  D., 

Physician  to  the  Northwest  London  Free  Dispensary  for  Sick  Children. 

A  PRACTICAL  TREATISE   ON   THE  WASTING   DISEASES  OF 

INFANCY  AND  CHILDHOOD.  Second  American,  from  the  second  revised  and  enlarged 
English  edition.  In  one  handsome  octavo  volume,  cloth,  $2  50.  {Lately  Issued.) 
This  is  in  every  way  an  admirable  book.  The 
modest  title  which  the  author  has  chosen  for  i  t  scarce- 
ly conveys  an  adequate  idea  of  the  many  tubjects 
upon  which  it  treats.  Wasting  is  so  constant  an  at- 
tendant upon  the  maladies  of  childhood,  that  a  trea- 
tise upon  the  wasting  diseases  of  children  must  neees 
iarily  embrace  the  consideration  of  many  afTeclious 
of  which  it  is  a  symptom  ;  and  this  is  excellently  well 
done  by  Dr.  Smith.     The  book  might  fairly  be  de- 


scril:)e(l  as  a  practical  handbook  of  the  common  dls 
eases  of  children,  so  numerous  are  the  affections  con- 
sidered either  collaterally  or  directly.  We  are 
acquainted  with  no  safer  guide  to  the  treatment  of 
children's  diseases,  and  few  works  give  the  insight 
into  the  physiological  and  other  peciiliarities-  of  chil- 
dren that  Dr.  Smith's  book  does. — Brit.  Med.  Journ., 
April  8,  1871. 


Henry  C.  Lea's  Publications — (Diseases  of  Children).  21 

CfMITH  {J.  LE  WIS),  M.  D., 

^^  Professor  of  Mori/id  Anatomy  in  the  Bellevue  HoHpital  Med.  College,  N.  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.     Third  Edition,  revised  and  enlarged.     In  one  handsome  octave  volume 

of  726  pages.  Cloth,  $5  ;  leather,  $(').  (Now  Reudy.) 
The  eminent  success  which  this  worls  has  achieved  has  encouraged  tlie  autlior,  in  preparing 
this  third  edition,  to  render  it  even  more  worthy  th.nn  heretofore  of  the  favor  of  the  profession. 
It  has  been  thoroughly  revised,  and  very  considerable  additions  have  lieen  made  throughout. 
To  accommodate  these  the  volume  has  been  printed  in  a  smaller  type,  so  as  to  prevent  any 
notable  increase  in  its  size,  .nnd  it  is  presented  in  the  hope  that  it  tuny  attain  the  position  of 
the  American  text  boolc  on  this  important  department  of  medical  science. 

This  work  took  a  stand  as  an  autlKirily  from  its  first  edition  will  confirm  and  add  to  Its  reputation.  Having 
a|rpi>aranoo,  and  every  one  interested  in  studvinji  the  been  broujiht  up  to  the  prefunt  mark  in  llio  ra)  id  ad- 
diseases  of  which  it  treats  is  desirous  of  kuowiui;  what  vance  of  medical  .science,  it  is  tlie  best  work  in  our 
improvements  are  apparent  in  the  successive  editions,  lantruage,  on  its  ninue  of  topics,  for  the  .Vmerican  prac- 
The  principal  additions  to  which  we  refer,  and  which  titioner. — Pacific  Mfd.  and  Surg.  Jnurn.,  Feb.  Is" 6. 
will  be  the  distinsnishiug  features  of  the  third  editioD,  dj.  smith's  Diseases  of  Children  is  certainlv  the  most 
are  chapters  on  diphtheria,  cerebro-spinal  meniiijritis.  yni„al)le  work  on  the  subjects  treated  that  the  imicti- 
and  riJtheln.  The  former  disease  is  considered  much  !  tinner  can  provide  him.self  with.  It  is  fully  ahreast 
more  in  detail  than  formerly,  and  a  great  amount  of  ^.j.jj  g^,^>j.y  advance:  it  should  be  in  the  hand's  uf  prac- 
very  practical  information  is  added,  and  altogether  it  is  !  titioners  generally,  while,  because  of  the  cotici.^cness 
one  of  the  most  comprehensive  and  one  of  the  best  writ-  |  ^la)  clearness  of  style  of  the  writing  of  the  author,  every 
ten  chapters  of  the  subject  we  have  thus  far  read.     His  I  professor  of  diseases  of  clnldren.  if  he  has  not  already 


description  of  cerebro-spinal  meningitis,  founded  also 

for  the  most  part  on  per.sonal  experience,  is  aihnirably 

clear  and  exhaustive  — The  Med.  liecwd,  Feb.  19,  ]S76. 

In  presenting  this  deservedly  popular  treatise  for  the 


done  so,  should  adopt  this  as  bis  text-book. —  l'c<.  Medical 

Monthly,  Feb.  LS76. 
The  third  edition  of  this  really  valuable  work  is  now 

before  us.  with  a  hundred  pages  of  additional  matter, 
third  time  to  the  profession.  Dr.  Smith  has  given  it  a  ;  jj„  altered  size  of  page,  new  illustrations.  ,and  new  type, 
careful  preparation,  which  will  make  it  of  decided  su-  |  Qf  tj^g  diseases  treated  of  for  the  first  time,  we  notice 
periority  to  either  of  the  former  edition.'!.  The  position  \  ^otheln  and  cerebro-spinal  fever,  which  lately  |)revaile(i 
of  the  author,  as  physician  and  consultant  to  several  ;  j„  epidemic  form  in  .some  parts  of  the  country.  The 
large  children's  ho.^pitals  in  New  York  city,  has  fur-  I  article  upon  diphtheria,  containing  the  latest  develop- 
nished  him  with  constant  occasions  to  put  his  treatment  menls  in  the  pathology  and  treatment  of  that  dread  dis- 
to  the  test,  and  his  work  has  at  once  that  practical  and  case,  which  f?o  lately  ravaged  our  country,  is  peculiarly 
thoughtful  tone  which  is  a  marked  characteristic  of  the  interesting  to  every  practitioner.  We  gladly  welcome 
best  productions  of  the  American  medical  press. — Med.  this  standard  work,  and  cheerfully  recommend  it  to  our 
mid.  Surg.  Reporter,  Feb.  1876.  readers  as  the  best  on  this  subject  in  the  Knglisli  lan- 

The  former  editions  of  this  book  have  given  it  the  [  ^w?^%e.— Nashville  Juurnal  of  Med.  and  Sursery,  March, 
highest  rank  among  works  of  its  class,  and  the  present  ,  1S76. 


{ION J) IE  {D.  FRANCIS),  M.I). 

^  A  PRACTICAL  TREATISE  OX  THE  DISEASES  OF  CHILDREN 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely 
printed  pages,  cloth,  $5  25  ;  leather,  $6  25. 
The  present  edition,  which  is  the  sixth,  is  fully  np     ►eachers.     Ah  a  whole,  however   'l^* '^"'"^.•V''f„!^?r 


to  the  times  in  the  discussion  of  all  those  points  in  the 
pathology  and  treatment  of  infantile  diseases  which 
have  been  brought  forward  by  the  German  and  French 


American  one  that  we  have,  and  lu  its  special  adapta- 
tion to  American  practitioners  it  certainly  has  iio 
equal.  — i^V«)  York  Med.  Record,  March  2,  IbfiS. 


TfTEST  (CHARLES),  M.D., 

'  '  Physician  to  the  Hospitalfor  Siols  Children,  *c. 

LECTURES  ON   THE  DISEASES   OF  INFANCY  AND  CHILD- 

HOOD.  Fifth  American  from  the  si.xth  revised  and  enlarged  English  edition.  In  one  large 
and  handsome  octavo  volume  of  078  pages.  Cloth,  $4  ."iO  ;  leather,  $6  50.  {Jiift  Jffufd.) 
The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  translation  into  Oer- 
man,  French,  Italian,  Danish,  Dutch,  and  Russian,  show  that  it  fills  satisfactorily  a  want  exten- 
sively felt  by'the  profession.  There  is  probably  no  man  living  who  can  speak  with  the  authority 
derived  from  a  more  e.xtended  experience  than  Dr.  West,  and  his  work  now  presents  the  ['•■•^u''^"' 
nearly  2000  recorded  cases,  and  COO  post-mortem  examinations  selected  from  among  nearly  40,000 
cases  which  have  passed  under  his  care.  In  the  preparation  of  the  present  edition  he  has  omitted 
much  that  appeared  of  minor  importance,  in  order  to  find  room  for  the  introduction  of  additiona 
matter,  and  the  volume,  while  thoroughly  revised,  is  therefore  not  increased  materially  in  size. 

Of  all  the  English  writers  on  the  diseases  of  chil- 1  living  authorities  in  the  difflcnlt  de,wtmeut  of  med^- 
dren,  there  is  no  one  bo  entirely  satisfactory  to  us  as    cal  science  in  which  he  i«  most  widely  known.- 
Dr    West.    For  years  we  have  held  his  opinion  as     Boston  Med.  and  Surg.  Journal. 
]  udicial,  and  have  regarded  him  as  one  of  the  highest  | 

T)T  THE  SAME  AUTHOR.    (Lately Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 
HOOD- being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of  Lon- 
don, in  March,  1871.     In  one  volume,  small  12mo.,  cloth,  $1  00. 

DEWEES  ON   THE  PHYSICAL    AND   MEDICAL  TKEATMKNT   OF  CHILDBEN.      Eleveath  edition,     1 
vol.  fvj.  of  648  pages.    Cloth,  f2  80. 


22 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


fTHOMAS  {T.GAILLARD),M.D., 

Proffssor  tif  Obstntrics,  &c..  in  the  College  of  Physicians  and  Surgeons,  N.  T.,  &c, 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.   Fourth 

edition,  enlarged  and  thoroughly  revised.     In  one  large  and  handsome  octavo  volume  of 

800  pages,  with  191  illustrations.     Cloth,  $5  00;  leather,  $6  00.      (Just  Issued.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 

this  work  to  render  it  worthy  a  continuance  of  the  very  remarkalDle  favor  with  which  it  has  been 

received.     Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  has  been 

spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 

A  work  wbicli   has  reached   a  fourth   etlition.  and  i  eion  would  remark  that,  as  a  teacher  of  gjujecology. 


that.  too.  in  the  short  space  of  five  years,  has  achieved 
a  ivimtation  which  places  it  almost  beyond  the  reach 
of  criticism,  and  the  favorable  opinions  which  we  have 
already  expressed  of  the  former  editions  seem  to  re- 
quire that  we  should  do  little  more  than  announce 
this  new  issue.  We  cannot  refrain  from  saying  that, 
as  a  practical  work,  this  is  second  to  none  in  tlie  Eng- 
lish, or.  indeed,  in  any  other  lansruage.  The  .arranere- 
ment  of  the  contents,  the  admirably  clear  manner  in 
which  the  suhject  of  the  ditferential  di.aiino.sis  of 
several  of  the  diseases  is  handled,  le.ave  nothinir  to  he 
desired  hy  the  practitioner  who  wants  a  thorou'ihly 
clinical  work,  one  to  wiiich  he  can  refer  in  difficult 
cases  of  doubtful  diagnosis  with  the  certainty  of  (rain- 
ing lifrht  and  instruction.  Dr.  Thomas  is  a  man  with  a 
very  clear  head  and  decided  views,  and  there  seems  to 
be  nothius  which  he  so  much  dislikes  as  h.azy  notions 
of  dias^nosis  aud  blind  routine  and  unrea.sonable  thera- 
peutics. The  student  who  will  thoroughly  study  this 
book  and  test  its  principles  by  clinical  observation,  will 
certainly  not  be  guilty  of  these  faults. — London  Lancet, 
ieh.  13,  IST."). 

The  latest  edition  of  this  well-knowu  text-book 
retains  the  esseutial  characters  ^hich  re'ndered  the 
earliest  so  deservedly  popular  It  Is  siill  pre-emi- 
nently a  practical  manual,  intended  to  convey  to 
students  in  a  clear  and  forcible  manner  a  sufficiently 
complete  outline  of  gyusecology.  In  a  word,  we 
should  say  that  any  one  who  intended  to  make  a 
special  study  of  gyniecology  could  hardly  do  better 
than  to  begin  with  a  minute  perusal  of  this  book,  and 
that  aoy  one  who  intended  to  keep  gyuiecology  sub- 
ordinate to  geaeral  practice,  should  hardly  fail  to 
have  it  on  hand  for  future  reference. — N.  T.  Med. 
Journ  ,  Jan.  1875. 

Reluctantly  we  are  obliged  to  close  this  unsatis- 
factory notice  of  so  excellent  a  work,  and  in  couclu- 


both  didactic  and  clinical.  Prof  Thomas  hascertainly 
taken  the  lead  far  ahead  of  his  confrire.R,  and  as  an 
author  he  certainly  has  met  with  unusual  and  mer- 
ited succesis. — Aia  Journ.  of  Obstetrics,  Nov.  1874. 

This  volume  of  Prof  Thomas  in  its  revised  form 
is  classical  without  being  pedantic,  full  in  Ihe  details 
of  anatomy  and  palhology,  without  ponderous 
translation  of  pages  uf  German  literature,  describes 
distinctly  the  details  and  difficulties  of  each  opera- 
tion, without  wearying  aud  useless  minutia;,  and  is 
in  all  respects  a  work  worthy  of  confidence,  justify- 
ing the  high  regard  in  which  its  disliugai*hed  au- 
thor is  held  by  the  profession. — Am.  Supplement, 
Obsiet.  Journ.    Oct.   lS7-t. 

Prof6»sor  Thomas  fairly  took  the  Profession  of  tb« 
United  States  by  storm  when  his  book  first  made  i's 
appearance  early  in  IStiS.  Its  reception  was  simply 
enthusiastic,  notwithstanding  a  few  adverse  criti- 
cisms from  our  transatlantic  brethren,  the  first  large 
edition  was  rapidly  exhausted,  and  in  six  mouths  a 
second  one  was  issued,  aud  in  two  years  a  third  one 
was  announced  aud  published,  and  we  are  now  pro- 
mised the  fourth.  The  popularity  of  this  work  was 
not  ephemeral,  aud  its  success  was  unprecedented  in 
the  annals  of  American  medical  literature.  Six  years 
is  a  long  period  in  medical  scientific  research,  but 
Thomas's  work  on  "  Diseases  of  Women"  is  still  the 
leading  native  production  of  the  United  States.  Tlie 
order,  the  matter,  the  absence  of  theoretical  disputa- 
tiveness,  the  fairness  of  statement,  and  the  elegance 
of  diction,  preserved  throughout  the  entire  range  of 
the  book,  indicate  that  Professor  Thomas  did  not 
overestimate  bis  powers  when  he  conceived  the  idea 
and  executed  the  work  of  producing  a  new  treatise 
upon  diseases  of  women. — Prof.  Pallen,  in  Louis- 
ville Med.  Journal,  Sept.  1S71. 


B 


ARNES  [ROBERT),  M.D.,  F.R.C.P., 

Obstetric  Physician  to  St.  Thomas's  Hospital,  de. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL DISEASES  OF  WOMEN.  In  one  handsome  octavo  volume  of  about  800  pages,  with 
169  illustrations.     Cloth,  $5  00;  leather,  $6  00.     (Just  Issued.) 

sion  with  which  his  name  has  so  long  been  honorably 
connected.  To  attempt,  however,  an  exhaustive  an- 
alysis of  so  voluminous  a  treatise  would  carry  us  far 
beyond  all  reasonable  bounds.  —  Glasgow  Med. 
Journ.,  July,  1874. 

Embodying  the  long  experience  and  personal  obser- 
vation of  one  of  the  greatest  of  living  teachers  in  dis- 
eases of  women,  it  seems  pervaded  by  the  presence 
of  the  author,  who  speaks  directly  to  the  reader,  and 
speaks,  too,  as  one  having  authority.  And  yet,  not- 
withstanding this  distinct  personality,  there  is  noth- 
ing narrow  as  to  time,  place,  or  individuals,  in  the 
views  presented,  and  in  the  instructions  given;  Dr. 
Barnes  has  been  an  attentive  student,  not  only  of  Eu- 
ropean, but  also  of  American  literature,  pertaining  to 
diseases  of  females,  and  euricbedUiis  own  experience 
by  treasures  thence  gathered  ;  he  seems  as  familiar, 
for  example,  with  the  writings  of  Sims,  Emmet,  Tho- 
mas, and  Peaslee.  as  if  these  eminent  men  were  his 
countrymen  and  colleagues,  and  gives  them  a  credit 
which  must  be  gratifying  to  every  American  physi- 
cian.— Am.  Journ.  Med.  Sci.,  April,  1874. 

Throughout  the  whole  book  it  is  impossible  not  to 
feel  that  the  author  has  spontaneously,  conscientious- 
ly, and  fearlessly  performed  his  task.  He  goes  direct 
to  the  point,  and  does  not  loiter  on  the  way  to  gossip 
or  quarrel  with  other  authors.  Dr.  Barnes's  book 
will  be  eagerly  read  all  over  the  world,  and  will 
everywhere  be  admired  for  its  comprehensiveness, 
honesty  of  purpose,  and  ability  — The  Ob.Het.  Journ, 
of  Great  Britain  and  Ireland,  March,  !S74. 


Dr.  Barnes  is  not  only  a  practitioner  of  exception- 
ally large  oi)portnnities,  which  he  has  used  well,  but 
he  has  kept  himself  informed  of  what  has  been  said 
and  done  by  others;  aud  he  has  in  the  present  vol- 
ume judiciously  used  this  knowledge.  We  can 
strongly  recommend  Dr.  Barnes's  work  to  thegyna;- 
colo.^ical  student  and  practitioner. — J!f.  Y.  Med.  Rec- 
ord, June  l.i,  1874. 

We  can  only  repeat  that,  as  a  thoroughly  sound, 
practical,  clinical  treatise,  we  know  of  no  English 
work  which  can  compare  to  this  of  Dr.  Barnes.  To 
the  so-called  specialist,  as  well  as  to  the  general  prac- 
titioner, it  will  prove  a  most  useful  guide. — London 
Lancet,  Jan.  10,  1874. 

In  conclusion,  we  must  express  ourconviction  that, 
in  viev7  of  the  wide  range  of  subjects  compressed 
into  a  single  volume,  this  book  is  admirable  for  the 
Conciseness  and  clearness  with  which  practical 
points  are  treated,  and  evidently  from  a  large  expe- 
rience. For  students,  and,  indeed,  for  a  good  many 
of  those  who  for  want  of  time  cannot,  or  for  want  of 
inclination  will  not, be  students,  it  is  a  safe  and  sat- 
isfactory guide,  and  no  one  who  attempts  to  treat  the 
diseases  peculiar  to  women  can  atford  to  be  without 
it.  The  volume  is  profusely  illustrated  ;  many  of  the 
cuts  are  new  to  gyua;cological  literature,  and  most  of 
them  are  essential  adjuncts  to  the  text. — Boston 
Med.  and  Surg.  Journ.,  April  17,  1S74. 

Dr.  Barnes's  present  work  is  a  magnificent  contri- 
bution to  the  literature  of  that  branch  of  the  profes- 


Henry  C.  Lea's  Publications— (Diseases  of  Woftien). 


23 


H 


ODGE  (HUGH  L.),  3I.D., 

Emeritus  Professor  of  Obstetrics,  &o.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN;  including  Displacements 

of  the  Uterus.     With  original  illustrations.     Second  edition,  revised  and  enlarged.     In 
one  beautifully  printed  octavo  volume  of  5.31  pages,  cloth,  $4  50. 


From  Prof.  W.  H.  Btford,  of  the  Hush  Medical 
CdUege,  Chiengo. 

The  book  bears  the  impress  of  a  master  hand,  and 
mnst,  as  its  predecessor,  prove  acceptable  to  the  pro- 
fession. In  diseases  of  women  Dr.  Hodge  has  estab- 
lished a  school  of  treatment  that  has  become  world- 
wide in  fame. 


Professor  Hodge's  work  Is  trnly  an  original  one 
rem  beginul/ig  (o  end,  consequently  no  one  ran  pe- 
•nse  its  pages  without  learning  something  new.  As  a 
contribution  to  the  study  of  women's  diseases.  It  is  of 
great  value,  and  is  abundaiiflv  able  to  stand  on  llg 
own  merits.— .flT.  Y.  Medical  Record,  Sept.  16,  1888. 


-^EST  [CHARLES],  M.D. 

LECTURES  ON  THE  DISEASES  OF  WOMEN 

from  the  Third  London  edition 
$3  75  ;  leather,  $4  75. 


Third  American, 

In  one  neat  octavo  volume  of  about  550  pages,  cloth, 


As  a  writer,  Dr.  West  stands.  In  our  opinion,  se-  seeking  truth,  and  one  that  will  convince  the  student 


ccmd  only  to  Watson,  the  "Macaulay  of  Medicine;' 
he  possesses  that  happy  faculty  of  clothing  instrnc- 
tion  in  easy  garments  ;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  of  the  ancient  pro 
verb,  along  a  royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,  but 
it  is  one  that  will  please  the  great  majority  who  are 


that  he  has  committed  himself  to  a  candid,  safe,  and 
valuable  guide. — X.  A.  Med .-Chirurg  Review. 

We  have  to  say  of  it,  briefly  and  decidedly,  that  It 
is  the  best  work  on  the  subject  in  any  language,  and 
that  it  stamps  Dr.  West  as  the  fnciU  princeps  of 
British  obstetric  authors. — Edinburgh  Med.  Journal. 


DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition 
with  the  Author's  last  improvementsand  correc 
tions.  In  one  octavo  volume  of  536  pages,  wit> 
plates,  cloth.     *.S  no. 

CHURCHILL  ON  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN  1  vol. 
8vo.,  pp.  450,  cloth.     $2  50. 


.\SHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 
8vo.,  pp  52S,  cloth      $.S  50 

MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  I  vol.  8vo.,  pp. 
■^ea.  cloth.    *2  00. 


rpANNER  [THOMAS  H),  M.D. 
ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.     Fir.^t  AmericaD 

from  the  Second  and  Enlarged  English  Editi.n.  With  four  colored  plates  and  illustration* 
on  wood.  In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $4  25. 
With  the  immense  variety  of  subjects  treated  of.  We  recommend  obstetrical  students,  young  and 
and  the  ground  which  they  are  madeto  cover,  the  im-  (  old,  to  hav(  this  volume  in  their  collections.  Itcon 
possibility  of  giving  an  extended  review  of  this  truly  |  tains  not  onlj  afair  statement  of  the  signs,  symi)totn8, 
remarkable  work  must  be  apparent.  We  have  not  a  '  and  diseaset  of  pregnancy,  but  comprise!"  in  addition 
single  fault  to  find  with  it,  and  most  heartily  com-  I  much  interesting  relative  matter  thai  is  not  to  be 
mend  it  to  the  careful  study  of  every  physician  who  found  in  an.T  other  work  that  we  can  name. — Edin- 
would  not  only  always  be  sure  of  his  diagnosis  of  I  burgh  Med.  Journal,  Jan.  1S68. 


fTHE  OBSTETRICAL  JO  URNAL.     [Free  of  postage  for  1876.) 

THE    OBSTETRICAL   JOURNAL   of  Great   Britain   and  Ireland; 

Including  Midwifery,  and  the  Disea.ses  op  Women  and  Infants.  With  an  American 
Supplement,  edited  by  J.  V.  I.ngham,  M.D.  A  monthly  of  about  80  octavo  pages, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.  Single  Numbers,  50 
cents  each. 

Commencing  with  April,  187.3,  the  Ob.'itetricnl  Journal  consists  of  Original  Papers  by  Brit 
ish  and  Foreign  Contributors  ;  Transactions  of  the  Obstetri.-al  S..cieties  in  En^'land  and  Bl>road 
Reports  of  Hospital  Practice;  Reviews  and  Bibliographical  Notices;  Articles  and  Notes,  bdito 
rial  Historical,  Forensic,  and  Misoelliineous ;  Selections  from  Journals;  Correspomlence  *o 
Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this  important  and  ra 
pidly  improving  department  of  medical  science,  the  value  of  the  information  which  it  pre 
sents  to  the  subscriber  may  be  estimated  from  the  character  of  the  genljemen  who  have  a  rendy 
promised  their  support,  including  such  names  as  those  of  Drs.  Atthili.,  Uobkkt  Barnks  II  hnky 
Bennet,  Thomas  Chambers,  Fi,EETwaon  Ci.uRoniLi,.  Matthews  Ditncan  (3raii.v  Hkwitt, 
Braxton  Hicks,  Alfred  Meadows,  W.  Le.shman,  Ale.x.  Simi'son  Tyler  Smith.  ^^y^^J- 
Tilt,  Spencer  Wells,  Ac.  Ac.  ;  in  short,  the  representative  men  of  British  Obstetrics  and  Ujnas- 
oology. 

In  order  to  render  the  Obstetrical  Journal  fully  adequate  to  the  wanta  of  the  Ainerican 
profession,  each  number  contnins  a  Supplement  devote.!  to  the  advances  made  in  Obstetrics  and 
Gvna?coIogv  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  is  under  the  editorial 
charge  of  Dr.  J.  V.  Ingham,  to  whom  editorial  communications,  exchanges,  books  lor  re- 
view, &c.,  may  be  addressed,  to  the  care  of  the  publisher. 

*,*  Complete  sets  from  the  beginning  can  no  longer  be  furnished,  but  subscriptions  can  com- 
mence  with  January,  1876,  or  with  Vol.  IV.,  April,  187d.  ^ 


24 


Henry  C.  Lea's  Publications — {Midwifery). 


JTODGE  [HUGH  L.),  M.  D., 

•*-*  Emeritw)  Profennor  of  Midwifery,  &c. ,  in  the  University  of  Pennsylvania,  Ac. 

THE    PRINCirLES  AND   PRACTICE   OF   OBSTETRICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  fron) 
original  photographs,  and  with  numerous  wood-cuts.     In  one  large  and  beautifully  printed 
quarto  volume  of  650  double-columned  pages,  strongly  bound  in  cloth,  $14. 
The  work  of  Dr.  Hodge  is  somptliing  more  than  a  obstetricians.    Of  the  American  works  on  the  subject 
jimple  presentation  of  his  particular  views  in  the  de-  it  is  decidedly  the  best. — Edinh.  Med.  Jour.,  Dec.  '64. 
partment  of  (Obstetrics;  it  is  something  more  than  an|      We  have  read  Dr.  Hodge  s  book  with  great  ple'»- 
ordinary  treatise  on  midwifery ;  it  is,  in  fact,  a  cyclo-j  sure,  and  have  much  satisfaction  in  expressing  oai 
psedia  of  midwifery.     He  has  aimed  to  embody  in  a  commendation  of  it  as  a  whole.    It  is  certainly  highly 
single  volume  the  whole  science  and  art  of  Obstetrics. !  instructive,  and  in  the  main,  we  believe,  correct.   Tb« 
An  elaliMiatP  text  is  combined  with  accurate  and  va-' great  attention  which  the  author  has  devoted  to  the 
ried  pictorial  illustrations,  so  that  no  fact  or  principlel  mechanism  of  parturition,  taken  along  with  the  con- 
left  unstated  or  unexplained. — Am.  Med.  Times,  elusions  at  which  he  has  arrived,  point,  we  think, 


Sept.  .3,  1S64. 

It  IS  very  large,  profusely  and  elegantly  illustrated' 
and  i.s  fitted  to  take  its  place  near  the  works  of  great 

***  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail 
on  receipt  of  six  cents  in  postage  stamps. 


conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Glasgow  Med.  Journal,  Oct.  1864. 


pLA  YFAIR  (  W.  S.\,  M.D.,  F.R.C.P.. 

-*-  Prnfefsnr  of  Oh.stefric  Medicine  in  King's  College,  etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  I\riDWTFERY. 

In  one  handsome  octavo  volume  of  576  pages,  with  166  illustrations  :  cloth,  $4  00;   lea- 
ther, S5   00.      {Just  Ready) 

The  distinguished  reputation  of  the  author  is  sufficient  assurance  that  this  volume  will  fully 
effect  its  object  of  presenting  to  the  practitioner  and  student,  within  a  moderate  compass,  a  trust- 
worthy work  of  reference  and  text-book  on  obstetrics  in  its  most  modern  aspect. 

We  cungratiilate  the  profession  and  Dr.  Playfair  ing  the  science  and  practice  of  obstetric  medicine, 
on  the  api'Paiituce  of  this  most  valuable  work.  We  that  we  possess  two  iii.muals  which  fairly  represeut 
find  his  practical  recommendations  to  be,  on  (be  the  actual  state  of  our  knowledge,  thai  may  be  geni- 
whole.  sound  and  simple.  The  work  is  an  excellent  ;  rally  trusted  for  the  information  they  contain,  and 
one.  We  need  scnrcely  say  that  we  recommend  it  to  for  the  jndgment  with  which  it  is  set  forth.  Boih 
practitioners,  teachers,  and  students.  It  issecondary  I  works  are  written  with  considerable  ability.  The 
to  no  similar  treatise  in  the  language  ;  superior  to  style  of  Leishman  is  graceful,  clear,  orderly,  and 
most — Edininirgh  Med.  Jo^irn.,  Jaly,  \&16.  ;  flowing.    It  is  most  pleasant  reading.    Dr,  Playfair's 

We  have  Leiihman  a.nd  Playfair-text-books  of  ^  capacity  for  seizinga  subjeclRnd  placingit  in  aclear 
the  best  kind— and  we  may  cougratulaie  these  who  '  ^'S'^'  before  tte  reader  is  conspicuous.— Brit,  and 
teach,  those  who  practise,  and  those  who  are  learn-    -f''-"'-  Med.-Clur.  Rev.,  Julj,  Ib/G. 


S^WAYNE  {JOSEPH  GRIFFITHS),  M.D., 

^^  Physician-Accoucheur  to  the  British  General  Hospital,  &o. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 

MENCING  MIDWIFERY  PRACTICE.     Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M.  D.     With  Illustrations.     In  one 
neat  12mo.  volume.     Cloth,  $1  25.     {Lately  Issued.) 
***  See  p.  3  of  this  dialogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 

It  is  really  a  capital  little  compendium  of  the  snb-  •  ries  the  most  important  practical  suggestions  it  con- 
Ject,  and  we  recommend  youngpractitioners  to  buy  it  ,  tains.  The  American  editor  has  materially  added  by 
and  carry  it  with  them  when  called  toattend  cases  of  his  notes  and  the  concluding  chapters  to  the  corn- 
labor.  They  can  while  away  the  otherwise  tedious  pleteness  and  general  value  of  the  book. — Chicago 
hours  of  waiting,  and  thoroughly  fix  in  their  memo-  j   Med.  Journal,  Feb.  1870. 


T\riNCKEL  (F.), 

'  '  Professor  and  Director  of  the  Gynecological  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.     Translated,  with  the  consent  of 
the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M.D.     In  on«» 
'^otPvo  volume.     Cloth,  $4  00.     (Now  Ready  ^ 
The  subjects  treated  of  in  this  volume,  while  of  primary  importance  to  the  practitioner,  are 
such  as  have  heretofore  not  received,  in  sj'stematic  treatises,  the  detailed  attention  which  they 
deserve.     Occupying,  as  the  work  does,  a  middle  ground  between   obstetrics  and  gynaecology,  it 
is  believed  that  it  will  fill  an  acknowledged  want  in  medical  literature,  while  the  high  reputation 
which  it  has  acquired  abroad  and  the  minute  details  of  treatment  which  it  presents  are  an  assur- 
ance that  it  will  be  considered  here,  as  in  Germany,  a  book  of  the  highest  authority  for   daily 
reference.     The  additions  furnished  by  the  Author  to  the  Translator  render  it  fully  on  a  level 
with  the  existing  state  of  science. 


We  feel  quite  sure  that  the  profession  of  this  country 
will  give  this  interesting  and  learned  work  a  cordial 
welcome.—  Cincinnati  Mid.  News,  .Tune,  1S"6. 

In  Germany  this  treatise  is  regarded  as  a  standard 
authority  in  this  branch  of  medicine,  and  as  it  con- 
tains tlie  reeent  advances  in  the  pathology  and  treat- 
ment of  diseases  that  pertain  to  thepuerjieral  condition, 
will  be  u'ladly  received  by  a  larsre  portion  of  the  profes- 
sion in  this  country. — Cincinnati  Lancet  and  Observer, 
June,  18TB. 

Tins  work  was  written,  as  the  author  tells  us  in  his 


preface,  to  supply  a  want  arising  from  the  very  brief 
consideration  given  to  puerperal  diseases  bj'  writers  on 
Obstetrics,  iu  which  respect  it  seems  the  profession  in 
his  country  is  not  different  from  ours,  and  to  fill  a  blank 
left  between  the  treatises  upon  the  subject  already  in 
the  field,  and  the  present  standpoint  of  science.  The 
work  has  reached  a  second  edition,  and  bears  evidence 
throu'.:hout  of  careful  study  and  practical  experience. 
-As  its  title  implies,  it  is  a  manual  rather  than  a  treatise. 
— American  Journal  of  Med.  Sciences,  April.  l&Tl. 


^      Henry  C.  Lea's  Publications — (Midwifery).  25 

''^EISHMAN  {WILLIAM),  M.D., 

Regius  Profossor  of  Midwifi-ry  in  the  ITiiiversity  <</  Glaxgow,  &e. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Second  American,  from  the  Second 
and  Revised  English  Edition,  with  additions  by  Jons  S.  Paurv,  M.l).,  Obstetriciiin  to  the 
Philadelphia  Hospital,  &c.  In  one  large  and  very  handsome  octavo  volume  of  over  700 
pages,  with  about  two  hundred  illustrations  :  cloth,  $5  ;  leather,  $6.     {Now  Reaily  ) 


But  the  most  valuable  aJditions  to  the  volume  are 
those  matle  by  the  American  editor.  One  of  the  best  te.sts 
ot  a  man's  ability  is  for  him  to  take  a  stiinilard  work  in 
our  profession,  like  this  of  Dr.  Leishman.  and  materially 
improve  it.  Many  a  one,  with  more  ambition  than  wis- 
dom, has  attempted  it  with  oilier  books  and  failed.  But 
Dr.  Parry  has  succeeded  most  admirably.  We  know  no 
obstetrical  work  that  lias  anytliiug  better  on  the  use  of 
the  forceps  than  that  which  Dr.  Parry  has  given  in  this, 
and  no  work  that  has  the  rational  and  intelligent  views 
upon  lactation  with  which  he  has  enriched  this.  Having 
used  '•Leisbmau"  for  two  years  as  a  textbook  for  stu- 
dents, we  can  cordially  commend  it,  and  are  quite  satisfied 
to  continue  such  use  now. — Am.  Practitioner,  Mar.  1876. 

This  new  edition  decidedly  confirms  the  opinion  which 
we  expressed  of  the  first  edition  of  the  work,  in  the  May, 
lS7i,  uumbHr  of  this  Journal,  that  this  is  "the  best 
modern  W(  rk  on  the  subject  in  the  Engli.sh  language." 
The  excellent  practical  notes  contributed  by  Dr.  Parry 
refer  principally  to  the  use  of  the  forceps,  lactation,  and 
the  puerperal  diseases,  and  are  intended  to  increase  the 
usefulness  of  the  work  in  this  country.  An  entirely  new 


its  present  .shape,  is  a  great  improvement  on  its  prede- 
cessor, and  in  recommending  it  as  the  one  obstetrical 
text-book  which  we  should  advise  every  Knglish  speak- 
ing practitioner  and  student  to  buy. — Amencan  Jour- 
nal of  Obstetrics,  Feb.  1&76. 

Perhaps  the  most  useful  one  the  student  can  procure. 
Some  important  additions  have  been  made  by  the  editor, 
in  order  to  adajil  the  work  to  the  profession  iu  Ibis  coun- 
try, and  some  uew  illustrations  have  been  introduced, 
to  represent  the  obstetrical  instruments  genenilly  em- 
ployed in  Amencan  practice.  In  it«  present  form,  it  is 
an  exceedingly  valuable  book  for  both  the  student  ami 
practitioner. — Atw;  I'ork  Med.  Journal,  Jan.  Ib'G. 

In  about  two  years  after  the  L'ssueof  this  excellent 
treatise  a  second  edition  has  been  called  for.  We  regard 
the  treatise  as  thoroughly  sound  and  practical,  and  one 
which  may  wilh  confidence  be  con;  ulted  in  any  emet^ 
gency. — The  London  Laitcel,  Dec.  11,  lb76. 

The  appearance  of  a  second  edition  of  this  System  is 
the  fulfilment  of  the  prophecy  which  we  made  in  a 
former  review,  that  the  book  was  destined  to  •become  a 


(Aapter  on  diphtheria  of  puerperal  wounds  has  been  '  favorite."     The  additions  by  Dr.  Parry  are  usually  not 

added  (Dr.  P.  has  had  unusual  experience  in  this  form  abundant,  but  certain  places  which  are  pointed  out  aa 

of  puerperal  fever),  and  also  a  number  of  illustrations  the  weak  part  ol'  Dr.  Lei.shman"s  handicraft  have  been 

of  the  principal  obstetrical  in.strumeuts  in  use  in  Ame-  gre.itly  strengthened  by  abundant  and  very  judicious 

rica.   We  have  no  hesitation  in  saying  that  the  work,  in  addenda.— i'/u'iud.  Med.  Times,  Dec.  :20,  1S75. 


PAMSBOTHAM  [FRANCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  <tc.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  id 
all  nearly  200  large  and  beautiful  figures.     $7  00. 


flHURCHILL  [FLEETWOOD),  M.D.,  M.R.I. A. 

ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.     A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D  Feancis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  ol  Ch.U 
dren  "  <fcc  With  one  hundred  and  ninety-four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Cloth.  $4  00  ;  leather,  $6  00. 


JDARRY  [JOHN  S.),  M.D., 

^  O'^.tetrician  to  the  PUiladelpHa  Hospital.  Vic.-PreM.  ofiUe.  O^stet  S  ^ctdynf  ^'^''^'^^'P^'- 

FXTR\-UTERINE    PREGNANCY:    ITS    CLINICAL    HIS  TORY, 

DIAGNOSIS,    PROGNOSIS,  AND    TREATMENT.     In  one   handsome  octavo  volume. 

Cloth,  $2  60.'     {Now  Ready.) 


It  is  with  genuine  satisfaction,  therefore,  that  we  read 
tlie  work  betbre  us,  which  is  far  in  advance  of  any  mo- 
™rh  upon  the  subject  in  the  English  language,  and 
^<?X.'  very  much  in  the  number  of  cases  upon 
XcS  itls  bas«l,  we  believe,  any  work  of  the  kind  ever 
published.  The  author  has  given  great  care  and  .study 
?o  the  work,  and  has  handled  his  «'»'.,sl.cs  with  ,ud^- 
ment;  so  that,  whatever  was  to  be  t''i''''-f  _  f^om  hem 
he  has  "ained  and  added  to  our  know  edge  on  ihe  ""» 
je^t  %Ve  owe  the  author  munh  tor  giving  us  «  e,ear, 
Readable  book  upon  this  tope  He  .l^'^;- -^J"  *;ji'„^ 
at  ure^ent  possible,  removed  the  obscurity  attending 
^rteSi  points  of  the  subject.    He  has  brought  order 


out  of  something  very  like  chws.—Philadflphui  M'J. 
Times.  Keb.  I'J,  ls7fi. 

In  this  work  Dr.  Parry  has  B<ldcJ  a  most  valuable 
contribution  toobstetric  literature,  and  •me  wlil.-h  niectB 
a  want  long  f.-lt  by  thuse  of  the  pmfessr  n  who  have 
ever  been  called  upon  to  deal  with  this  cla*s  of  eases.— 
Ji'isum  Med.  and  Surrj.  Journ..  March  9,  Isxb. 

Thi«  work,  being  as  near  as  poi«sible  a  collection  of  the 
experiences  of  many  persons,  will  alTord  a  most  useful 
guide,  both  in  diagnosis  and  tr.alnicnt.  for  ibis  most 
interesting  and  fatal  malady.  Wo  think  it  should  be  in 
the  liandsol  all  physicians  practising  midwifery.— tin- 
cinnati  Clinic,  Veb.  5,  1676. 


Inlvol.Syo.,ofaearlybUOpp., cloth.   *3  7o.  ¥«ao. 


26 


Henry  C.  Lea's  Publications — (Surgery). 


/^KOSS  (SAMUEL  D.),  M.D., 

^-^  Proftssor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

A  SYSTEM  OF  SUEGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.     Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.     Fifth  edition, 
carefully  revised,  and  improved.    In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pages,  strongly  bound  in  leather,  with  raised  bands,  $15.    {Just  Issued.) 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.    In  the 
present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully  up  to 
the  day.     To  effect  this  a  large  jiart  of  the  work  has  been  rewritten,  and  the  whole  enlarged  by 
nearly  one-fourth,  notwithstanding  which  the   price  has  been  kept  at  its  former  very  moderate 
rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  o)  matter  is 
condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary  octavos. 
This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding,  renders 
it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly  belonging  to  the 
domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be  said  to 
have  in  it  a  surgical  library. 


We  biiTe  now  bnai^'lit  our  task  to  a  conclusion,  and 
have  seldom  read  a  work  with  tlie  practical  Vidue  of 
which  we  have  been  uioreimpres.«cd.  Kvery  cliapter  is 
so  conci!<ely  put  together,  that  the  busy  pracliiiouer, 
when  in  difficulty,  can  at  once  find  the  iutoimation  he 
requires.  Uis  work,  on  the  coutraiy,  is  cosmopolitan, 
the  surgery  of  the  world  being  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unjirejudiced,  and  so 
eniiueutly  practical,  that  it  is  almost  a  false  compliment 
to  say  that  we  believe  it  to  be  destined  to  occupy  a  fore- 
most place  asaworli  of  reference,  while  a  systt-m  of  sur- 
gery like  the  preseut  system  of  surgery  is  the  practice  of 
surgeons.  The  printing  and  biuUiug  of  the  work  is  un- 
exceptionable ;  indeed,  it  contrast;^,  in  the  latter  re- 
spect, remarkably  witti  i;nglish  medical  and  surgical 
cloth-bouud  publications,  which  are  generally  so  wretch- 
eflly  stitched  as  to  require  re-binding  before  they  are 
auv  time  in  use. — Vuti.  Jourii.  of  MaX.  Soi.,  March,  1S74:. 
Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  lorm. 
Thedillerence  in  actual  number  of  pages  is  no  I  more  than 
130,  but.  the  sine  of  the  page  having  been  increased  to 
what  we  believe  is  technically  termed  -elephant,"  there 
has  been  room  for  considerable  additions,  wliich,  toge- 
ther with  the  alterations,  are  improvements, — Lvnd. 
Lancet,  Nov.  IG,  1S72. 

It  combines,  as  perfectly  as  possible,  the  qualitie,s  of 
a  tc-it-buok  and  work  of  reference.  We  think  this  last 
edition  of  Utos.-^'s  "Surgery,''  will  confirm  his  title  of 


"  Primus  inter  Pares."  It  is  learned,  scholar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  so  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter, 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience. — iV.  1". 
JJed  Journ.,  i'eb.  1873. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery'  in  the  Knglish  language. — Ht. 
Louts  Medical  and  Surg.  Journ.,  Uct.  1S72. 

The  two  magnificeut  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  plea.sure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  u 
work  of  unrivalled  excellence;  and  now  we  have  tlus 
result  of  years  of  experience,  labor,  and  study,  all  con- 
den,sed  upon  the  great  work  before  us.  And  to  students 
or  practitioners  desirous  of  enriching  their  lil)rary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research  — 
Cincinnati  Lancet  and  Observer,  Sept.  lt:72. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations,  but  a  scientitic  account  uf  surgical  theory 
and  practice  in  all  its  departments. — Brit.aud  For.  Med.- 
Chir.  Kec,  Jan.  1873. 


T^r  THE  SAME  AUTHOR. 

A    PRACTICAL    TREATISE    ON  THE    DISEASES,   INJURIES, 

and  MalTormations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.     Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samukl   W .  (iaoss,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.     In  one  handsome  octavo  volume  of  674  pages,  with  170  illus- 
trations:   oloth,  $4   60.      (Now  Heady.) 
The  editor  has  availed  himself  of  the  opportunity  afforded  by  the  call  for  a  new  edition  of  this 
work  to  thoroughly  revise  and  render  it  in  every  respect  worthy  ol  its  position  as  a  standard  au- 
thority.    Being  in  great  part  rewritten,  the  opportunity  has  been  taken  to  condense  it  as  much 
as  possible,  so  that  it  will  be  found  reduced  in  size,  while  yet  containing  the  latest  views  on  the 
subjects  discussed. 

THE  SAME  AUTHOR. 


b' 


A  PRACTICAL    TREATISE    ON    FOREIGN    BODIES  IN   THE 

AIR-PASSAQES.     In  1  vol.  8vo.,  with  illustrations,  pp;  468,  cloth,  $2  75. 


G 


OSSELIN  (L.), 

Professor  of  Surgery  in  the  Faculty  of  Medicine,  Paris,  etc. 

CLINICAL  LECTURES  ON  SURGERY.     Delivered  at  the  Hospital 

of  La  Charite.  Translated  from  the  French  bj*  Lewis  A.  Stijison,  M.D.,  Surgeon  to  the 
Presbyterian  Hospital,  New  York.  With  illustrations.  {Pubiishitig  i/i  the  Medical  News 
and  Library  for  18i6.) 

S,TJTi/L:S!JLAJ£<.-^    OF    COlsTTEIsTTS. 
Part  I.  Surgical  Diseases  of  Youia— 8  Lectures.  I  Pakt  IV.  TRAUiiAiie  Fever.  Septicemia,  ic. — 4  Lect. 

II.  i'RACTUREs  OF  TiiE  Li.MBs — 18  Lectures.  I  V.  Diseases  of  the  AnTictLAXioxs— 7  Lectures. 

111.  Traumatic  Osteitis  and  Nkckosis— 2  Lectures.    |  'S'l.  Phlegmon,  Abscess,  Fistula — 3  Lectures. 

It  will  be  seen  from  this  brief  abstract  of  the  contents  that  these  Lectures  treat  of  subjects  which 
are  of  daily  interest  to  the  practitioner,  while  some  of  them  hardly  receive  in  the  text  books  the 
attention  which  their  importance  deserves.  The  very  distinguished  reputation  of  the  author  and 
the  practical  manner  in  which  he  has  handled  the  topics  before  him  are  sufficient  assurance  that 
this  work  will  be  in  every  way  satisfactory  to  the  subscribers  of  the  "Medical  News  and  Li- 
BKAltY  "  and  that  it  will  in  no  sense  detract  from  the  character  of  the  very  v.aluable  series  of  books 
which  have  occupied  the  Library  Depailment  of  the  "News"  duiing  the  last  thirty  three  years. 


Henry  C.  Lea's  Publications — (Surgery). 


21 


ASHHURST  {JOHN,  Jr.),  M.D., 

Sri.rge.on  to  the  Episcopal  Honpital,  Philadelphia. 

THE    PRINCIPLES   AND    PRACTICE   OF    SURGERY.     In  one 

very  large  and  handsome  octavo  volume  of  about  inOO  pages,  with  nearly  550  illustrationB 
cloth,  $6  50;  leather,  raised  bands,  $7  60.      (Lately  P^ihlished.)  ' 


Its  author  ha.-*  evidently  tested  the  writings  and 
experiences  of  the  past  and  present  in  the  crnclhle 
of  a  careful,  analytic,  and  honorable  mind,  and  faith- 
fully endeavored  to  bring  his  work  up  to  the  level  of 
the  highest  standard  of  practical  surgery.  He  is 
frank  and  definite,  and  gives  us  opinions,  and  gene- 
rally sound  ones,  instead  of  a  mere  re.5?(7nf  of  the 
opinions  of  others.  He  is  conservative,  but  not  hide- 
bound by  authority.  His  style  is  clear,  elegant,  and 
scholarly.  The  work  is  anadmirabletext-book,  and 
a  useful  book  of  reference      It  is  a  credit  to  Ameiican 


professional  literature,  and  one  of  the  first  ripe  fruits 
)f  the  soil  fertilized  by  the  l)lood  of  our  late  uulia]>py 
VAT.—N.  ¥.  Mud.  Record,  Feb    1,  1872 

n  gives  us  great  pleasure  to  call  the  attention  of  the 
profession  to  thisexcelleut  work  Our  knowledgeof 
its  talented  and  accomplished  author  led  us  to  expect 
from  him  a  very  valuable  treatise  upon  subjects  to 
which  he  has  repeatedly  given  evidence  of  havint  pro- 
fitably devoted  much  time  and  labor,  and  we  are  in  no 
way  disappointed.— P/ji/a.  Mtd.  Times,Feh.  1,  1872. 


H 


OLMES  [TIMOTHY),  M.D., 

Surgeon  to  St.  George's  Hospital,  London. 

SURGERY,  ITS    PRINCIPLES    AND    PRACTICE.     In   one  hand- 

some   octavo  volume  of  nearly  1000  pages,  with  411  illustrations.     Cloth,  $0;  leather,  $7. 
{Now  Ready.) 


We  believe  it  to  be  by  far  the  best  surgical  text-book 
that  we  have,  insomuch  as  it  is  the  complete^t,  and 
the  one  most  thoroughjy  brought  up  to  the  knowledge 
of  the  present  day.  All  who  will  give  this  book  the 
careful  perusal  that  it  deserves  and  requires,  <che- 
ther.student  or  practitioner,  will  agree  with  us,  that, 
from"  the  happy  way  in  which  justice  is  done,  both  to 
the  principles  and  practice  of  surgery,  from  the  care 
with  which  its  pages  are  brought  up  to  modern  date, 
from  the  respect  which  is  iiaid  all  along  to  the  opin- 
ions of  others,  it  deserves  to  take  the  first  place 
among  the  texi-booka  on  surgniy.  —  a ritish  Mtd. 
Journ,,  Dec.  2.9,  lS7o. 

This  is  a  work  which  has  been  looked  for  on  both 
sides  of  the  Atlantic  with  much  interest.  Mr.  Holmes 
is  a  surgeon  ot  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  biilliant 
writer  upon  surgical  subjecis  in  England.  It  i.s  a 
book  for  students— and  an  admirable  one— and  for 


the  busy  general  practitioner.  It  will  give  a  Ktiident 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  justifies  the  high  exjiectaiions 
that  were  formed  jf  it.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  conciseness  need'd 
to  bring  it  within  its  proper  limits  has  not  impaired 
its  force  and  distinctness. — N.  Y.  Med.  Record,  April 
14,  1S76. 

It  will  be  found  a  most  excellent  epitome  »f  stir- 
gery  by  the  general  praclilioner  who  ha*  not  the  time 
to  give  attention  to  more  minute  and  extendeil  works, 
and  to  the  medical  student.  In  fact,  we  know  of  no 
one  we  can  more  cordial  y  recomm«ud.  Tlie  author 
has  succeeded  well  ia  giving  a  plain  and  practical 
a'"Conut  of  each  surgical  injury  and  disease,  and  of 
the  treatment  which  is  most  coiuinonly  advisable. 
It  will  no  doubt  become  a  popular  w.irK  in  the  pio- 
fession,  and  especially  as  a  text-b'ook. — Vincinanii 
Med.  News,  April,  1S06. 


THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  Wii.LiA.vi  PiRKiE,  F.K  S.E.,  Professor  of  Surgery 
in  the  University  of  Aberdeen.  Edited  by  John 
Keill,  M.D.,  Professor  of  Surgery  in  the  Penna. 


Medical  College,  Surgeon  to  the  Pennsylvania  H  is- 
pital,  &c.  In  one  very  handsome  octavo  rolume  of 
780  pages,  with  31tj  illustrations,  cloth,  $.i  7j. 


tT/4  Ti  C  KNT  (F   Tf^    M  D 
^      ON   BANDAGING  AND    OTHER   OPERATIONS   OF   MINOR 

SURfiJERY.    New  edition,  with  an  additional  chapter  on  Military  Surgery.    One  handsome 
royal  1 2mo.  volume,  of  nearly  400  pages,  with  1«4  wood-cuts.     Cloth,  $1  76. 


rjA MIL  TON  ( FRANK  H),  M.D., 

*^  Professor  of  Pi-actures  and  Dislocations,  Ac,  in  Be.Uemie  Hosp.  Med.  College,  mo  York. 

A  PRACTICAL  TREATISE   ON   FRACTURES  AND   DISLOCA- 
TIONS.    Fifth  edition,  revised  and  itnproved.     In  one  large  and  handsome  octavo  volume 
ot  nearly  800  pages,  with  344  illttstrations.     Cloth,  *5  76:  leather,  $fi  75.     (Now  Ready.) 
Thi.  work  is  well  known,  abroad  as  well  as  at  home,  as  the  highest  authority  on  Us  itnportant 
,uSran  au7hoity  recognized  in  the  courts   as  well  as   in   the   schools  and  .n  pract.ce-.tnd 
,ga  n  Lanrfe:te7no^  only'by  the  demand  for  a  fifth  edition,  ^utj-y  --rtjnge^^nen  s  now  .n  pr.^^ 
crress  for  the  speedy  appearance  of  a  translation  in  Germany.     The  repe.ated  rexsions  «ii i.  ii  tne 

tx^hi^thj;  ^^z  opp--;;.--^- 1::  :r:ii;^x^;^:;  in  u::^;:;^t  i^^t 

aration  to  every  VojtAouo    'Y.' f^^^ll^""^^^^^^^  ^,^  incorporate  in  it  whatever 

£^^\!^aS^rl^:S^HX:i^tL'^:i;^;t"^^^^^^  P— -  -  the  con^ient 

hope  thafir will  more  than  maintain  its  very  distinguished  reputation. 

There  is  no  better  work  on  the  subject  in  existence '"^ 

than  that  of  Dr.  Hamilton.  It  should  be  '"^'he  P«^^«^ 
sion  of  every  general  practitiouer  and  surgeon.- J  «« 
Am.  Journ.  of  Obstetrics,  Feb.  lSi6. 

The  value  of  a  work  like  this  to  the  practical  p bysi- 
dan  and  VJirleon  can  ha-'ly  beover-estimate.h^am.  t  e 
necessity  of  bavinii  .such  a  book  revised  to  the  laiesi 
datC-tmer.'ronac  ountof  the  practical  importance 


of  its  teachings,  but  also  by  rea.-ion  of  the  modiw  cgal 
bearings  of  the  c.-uses  of  wliich  it  treats,  and  whu-  i  have 
recently  been  tlie  subject  of  useful  papers  by  Dr  lii'mi^ 
tou  anil  others,  is  suliiciently  obvious  to  every  one.  1  lie 
present  volume  seems  to  anii'lv  fill  n.l  the  re.nnsile*. 
We  can  safely  rcrommeud  it  as  llif  best  of  It.s  kind  m 
the  Ki.L'lisli  hin-uage.  .-.n.l  not  excelled  in  uiiy_ollior  — 
J-iitrn  ot'StTvous  anU  Menial  lH3tust,JaD.  Isit). 


28  Henry  C.  Lea's  Publications — (Surgery).  . 

PRICHSEN  {JOHN  E.), 

•*-'  Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 

gical  Injuries,  Diseases,  and  Operations.  Revised  by  the  author  from  the  Sixth  and 
enlarged  English  Edition.  Illustrated  by  over  seven  hundred  engravings  on  wood.  In 
two  large  and  beautiful  octavo  volumes  of  over  1700  pages,  cloth,  $9  00  j  leather,  $11  00. 
{Lately  Issued.) 

Author's  Prfface  to  the  New  American  Edition. 
On  no  former  edition  of  this  work  has  the  author  bestowed  more  pains  to  render  it  a  complete  and 
satisfactory  exposition  of  British  Surgery  in  its  modern  aspects.  Every  portion  has  been  sedu- 
lously revised,  and  a  large  number  of  new  illustrations  have  been  introduced.  In  addition  to  the 
material  thus  added  to  the  English  edition,  the  author  has  furnished  for  the  American  edition  such 
material  as  has  accumulated  since  the  passage  of  the  sheets  through  the  press  in  London,  so  that 
the  work  as  now  presented  to  the  American  profession,  contains  his  latest  views  and  experience. 
The  increase  in  the  size  of  the  work  has  seemed  to  render  necessary  its  division  into  two  vol- 
umes. Great  care  has  been  exercised  in  its  typographical  execution,  and  it  is  confidently  pre- 
sented as  in  every  respect  worthy  to  niaintain  the  high  reputation  which  has  rendered  it  a  stand- 
ard authority  on  this  department  of  medical  science. 

The.se  are  only  a  few  of  the  points  in  wbich  the  states  in  his  preface,  they  are  not  confined  toanyone 
present  edition  of  Mr.  Erichsen's  work  surpassea  its  portiou,  but  are  distribnted  generally  through  the 
predecessors.  Thronghout  there  is  evidence  of  a  subjects  of  which  the  work  treats.  Certainly  one  of 
laborious  care  and  solicitude  in  seizing  the  passing  the  most  valuable  sections  of  the  book  seems  to  n,s  to 
knowledge  of  the  day,  which  reflects  the  greatest  be  that  which  treats  of  the  diseases  of  the  arteries 
credit  ou  the  author,  and  much  enhances  the  value  and  the  operative  proceedings  which  they  necessitate 
of  his  work.  Wecau  only  adnnrc  the  industry  which  In  few  text-books  is  so  much  carefully  arranged  ia- 
has  enabled  Mr.  Erichsen  thus  to  succeed,  amid  the  fijrmation  collected. — London  Med.  Times  and  Gaz., 
distractionsof  active  practice,  in  producing  emphatic-  ,  Oct.  26,  1S72. 

ally  THi;  book  of  reference  and  study  for  British  prac-  l  The  entire  work,  complete,  as  the  great  English 
titioneis  of  surgery.— LoncZon  Lancet,  Oct.  26,  1S72.  I  treatiseonSurgery  .jf  our  own  time,  is,  we  can  assure 
Considerable  changes  have  been  made  in  this  edi-  our  readers,  equally  well  adapted  for  the  most  junior 
lion,  aud  nearly  a  hundred  new  illustrations  have  student,  and,  as  a  book  of  reference,  for  the  advanced 
been  added.  It  is  difficult  in  a  small  compass  to  point  ■  practitioner. — Dublin  Quarterly  Journal. 
out  the  alterations  and  additions  ;  for,  as  the  author  1 


SKET'S    OPERATIVE  SURGERY.     In  1   vol.    8vo.  ,      Laie  Professor  of  Surgery  in  the  University  of  Edin- 


oloth,  of  over  650  pages  ;  with  about  100  wood-cats. 
$3  25. 
COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
PracticeofSuegery.  In  1vol.  8vo.  cloth,  750 p.  $2. 


burirh.  Ac.  Fourth  American,  from  the  Third  and 
I!eTi.*ed  Edinburgh  Kdition.  In  one  larjie  and  very 
beautiful  volume  of  TOO  pages,  with  two  hundred  and 
forty  Illustrations  on  wood:  cloth,  $3  75. 


^„      „Ts  T.T,  .^^T^^  ^^  „,,„      THE  PRACTICK  OF  SURGERY.     By  James  Milier, 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR-        jj j,     ^0^,^],   American,  from  the  last  EdioburKh 

OERT.    Eighth  edition,  improved  and  altered.  With  |      jcjition   Revised  by  the  American  editor,   lllustiated 

thirty-four  plates.     In  two  handsome  octavo  vol-  l      v,y  three  hundred  and  sixtv-four  enp-avinRs  on  wood. 

umes,  abontlOOOpp., leather. raised  bandK.  )|!6  50.      j      j^   one  large  octavo  volume  of  nearly  700  pages: 

PRINCIPLES  OF  SURGERY.     By  James  Miller,  M.l).,  ]      cloth,  $3  75. 


D 


RUITT  {ROBERT),  M.R.  C.S.,  ^c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 

practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidate  every  Important  topic. 
We  nave  examined  the  book  most  thoroughly,  and 
can  say  that  this  success  is  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and  clas- 
sified, and  of  being  written  in  a  style  at  once  clear 
ind  succinct. — Am.  Journal  of  Med.  Scienceg. 


AH  that  the  surgical  student  or  practitioner  could 
d  jsire. — Duoiin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
r.hen  we  have  examined  one  with  more  pleasure. — 
I'ostou  Med.  a:id  Surg.  Journal. 


In  Mr.  Druitl's  book,  though  containing  only  some 
gGven  hundred  pages,  both   the  principles  and  the 


B 


A  SET  ON  {T.  J.). 
ON  THE  DISEASES,  INJURIES,  AND  MALFORMATIONS   OF 

THE  RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.  Second  Americ.^^, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  .300  pages,  cloth,  $3  25. 

IGELOW  [HENRY  J.),  M.  D., 

Professor  of  Surgery  in  the  Massachusetts  Med.  College. 

ON  THE   MECHANISM   OF    DISLOCATION  AND  FRACTURE 

OF  THE  HIP.  With  the  Reduction  of  the  Dislocation  by  the  Flexion  Method.  With 
numerous  original  illustrations.      In  one  very  handsome  octavo  volume.      Cloth,  $2  60. 

TA  WSON  (GEORGE),  F.  R.  G.  S.,  Engl, 

*-'  Assistant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  MoorJI^lds,  Ac. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS :  their  Imme- 

diate   and  Remote  Effects.     With  about  one  hundred  illustrations.     In  one  very  hand- 
some octavo  volume,  cloth,  $3  50. 

It  is  an  admirable  practical  book  In  the  highest  and  best  sense  of  the  phrase. — London  Medical  Timer 
ani,  Oaiettm,  May  18, 1867. 


Henry  C.  Lea's  Publications — (Surgery). 


29 


jyRYANT  [THOMAS),  F.R.G.S., 

'*-'  Surgeon  to  Guy's  Hospital. 

THE  PRACTICE    OF   SURGERY.     With  over  Five  Hundred  En- 
gravings on  Wood.     In  one  Inrge  and  very  handsome  octavo  volume  of  nearly  lOOO  pages 
cloth,  $6  25  ;  leather,  raised  bands,  $7  25.     (Lately  Puhllslied.) 
Again,  the  author  gives  us  his  own   practice,  liis 
owu  beliefs,  aud  illusti  atea  by  lii.s  own  cases,  or  thuhe 
treated  in  Guy's  Hospital.     This  feature  adds  joint 


ejnpliasis,  and  a  solidity  to  his  statements  that  inspire 
cunfldeuce.  One  feels  himself  almost  by  the  .side  of 
the  surgeon,  seeing  bis  work  aud  hearing  his  living 
words.     The  views,  etc,  of  other  surgeons  are  con- 


sidered calmly  and  fairly,  bat  Mr.  Bryant's  are 
adopted.  Thus  the  work  is  not  a  coiiqiilation  of 
other  writings;  it  is  not  an  eucyclopaidia,  hut  the 
plain  statements,  on  practical  points,  of  a  man  who 
has  lived  and  breathed  and  had  his  being  in  the 
richest  surgical  experience.— Z>e£roit  Review  <>/  Med. 
and  Pharmacy,  August,  1S73. 


A 


pARTER  [R.  BRUDENELL),  F.R.C S., 

^  Ojt'ithalniic  fiiirgton  to  St    Gtorge  s  tloKpilal,  itc. 

A  PRACTICAL  TREATLSE  ON  DISEASES  OF  THE  EYE.    Edit- 
ed, with  test-types  and  Additions,   by  John  Gi'.een,  JI.D.    (of  St.  Louis,  Mo.).     In  one 
handsome  octavo  volume  of  about  600  pages,  and  124  illustrations.     Cloth,  §3  75.     (Just 
Ready.) 
Dr.  Green,  whose  reputation  and  experience  in  this  department  are  well  known,  has  given  this 
work  a  very  careful  revision,  and  has  introduced  much  matter  which  will  be  found  of  iinpurtance 
to  the  practitioner.     As  his  system  of  test-types  is  the  one  recommer  ded  by  the  author,  they 
have  been   inserted  in  the  volume  in   a  shape  which   will  admit  of  their  being  detached  aud 
mounted  for  convenient  ofiBce  use. 

These  test-types,  on  a  sheet  for  mounting,  can  be  had  separate,  price  25  cents. 

It  would  be  dilhcult  for  Mr.  Carier  to  write  an  uniu-  -  in  view,  and  presents  the  suliject  in  a  clear  and  concise 
structive  book,  and  impossible  for  him  to  write  an  uu-  I  manner,  ca.«y  of  compreheusiou,  and  hem-e  the  more 
interesting  one.  Even  ou  subjects  with  which  he  is  not  I  valuable.  We  would  especially  commend,  however,  as 
bound  to  be  familiar,  he  can  discourse  with  a  rare  degree  I  worthy  of  high  praise,  the  manner  in  whicli  the  thera- 
of  clearness  and  effect.  Our  readers  will  therefore  not  |  jieutics  of  disease  of  the  e>e  is  elaborated,  for  here  the 
be  surprised  to  learn  that  a  work  by  him  on  the  Diseases  '  author  is  particularly  clear  and  practical,  where  other 
of  the  Hye  makes  a  very  valuable  addition  to  ophthal-  writers  are  unfortunately  too  often  deficient.  The  tinal 
mic  literature.  .  .  .  The  book  will  remain  one  useful  |  ciiapier  is  devoted  to  a  discussion  of  the  uses  and  selco 
aiike  to  the  general  and  the  special  practitioner.  Kot  [  tion  of  spectacles,  and  is  admirably  compact,  plain,  aud 
Uie  least  valuable  result  which  we  expect  from  it  is  that  ]  useful,  especially  the  paragraphs  on  the  treatment  of 
it  will  to  some  considerable  extent  despecialize  this  bril-  i  presliyopia  and  myopia.  In  conclusion,  our  thanks  are 
liant  department  of  medicine. — Loudon  Lancet,  Oct.  30,  duu  tlK-  author  for  many  useful  hints  in  the  great  sub- 
1875.  I  ject  of  ophthalmic  surgery  and   therapeutics,   a   field 

It  is  with  great  pleasure  that  we  can  endorse  the  work  I  ^^^'-'''^  o'' '»'«  y'-'^''"  Z''  F'*-"?"  "iV'  ''J."'^,  '^^."P"  ?^,''"""i' 
as  a  most  valuable  contribution  to  i>raclical  ophth;il- |  wheat  from  a  mass  of  chalr-.^e^«  iwt  J/c</.cu/ Aoorrf, 
niology.    Mr.  Carter  never  deviates  from  the  end  he  has  •  ^'^'-  -^'  1°'  5. 

J^ELLS  [J.  SOELDERG),' 

Professor  of  Ophthalmology  in  King's  College  Hospital,  <fec. 

TREATISE  ON  DISEASES  OF  THE  EYE.     Second  American, 

from  the  Third  and  Revised  London  Edition,  with  additions;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.     Together  with  selections  frota  the  Test-types 
of  Jaeger  and  Snellen.  •  In  one  large  and  very  handsome  octavo  volume  of  nearly  800 
pages;   cloth,  $5  00;   leather,  §6   00.      (Lately  Published.) 
The  continued  demand  for  this  work,  both  in  England  and  this  country,  is  suGcient  evidence 
that  the  author  has  succeeded  in  his  elfurt  to  supply  within  a  reasonable  compass  n  full  practical 
digest  of  ophthalmology  in  its  most  modern  aspects,  while  the  call  for  repeated  editions  has  en- 
abled him  in  his  revisions  to  maintain  its  position  abreast  of  the  most  recent  investigations  and 
improvements.     In  again  reprinting  it,  every  effort  has  been  made  to  adapt  it  thoroughly  to  the 
wants  of  the  American   practitioner.      Such  additions  as  seemed  desir.able  have   been   introduced 
by  the  editor,  Dr.  I.  Minis  Hays,  and  the  number  of  illustrations  has  been  largely  increased.     The 
importance  of  test-types  as  an  aid  to  diagnosis  is  so  universally  acknowledged  at  the  pre,-<ent  day 
that  it  seemed  essential  to  the  completeness  of  the  work  that  they  should  be  added,  and  as  the 
author  recommends  the  use  of  those  both  of  Jaeger  and  of  Snellen  for  different  purposes,  selec- 
tions have  been  made  from  each,  so  that  the  practitioner  may  have  at  command  nil  the  a.ssi.st- 
ance  necessary.     Although  enlarged  by  one  hundred  pages,  it  has  been  retiiined  at  the  former 
very  moderate  price,  rendering  it  one  of  the  cheapest  volumes  before  the  profession. 
A  few  notices  of  the  previous  edition  are  subjoined. 

On  examining  it  carefully,  one  is  not  at  all  sur-  lucid  and  flowing,  therein  differing  materinlly  from 
prised  Ihatit  should  meet  with  universal  favor,  it  someof  the  tianslaiious  of  Continental  writers  ..u  ihia 
is  in  fact  a  comprehensive  and  thoroughly  practical  subjects  thai  are  in  the  market.  Special  paiuH  are 
treatise  on  diseases  of  the  eye,  setting  forth  the  prac-  taken  to  explaih.at  length,  those  subjects  winch  »ra 
tice  of  the  leading  oculists  of  Europe  and  America,  particularly  dillicult  of  comprehension  to  the  begin- 
andgiviugtheauthor'sowuopiniousand  preferences,  ner,  as  the  use  of  the  ..phthalinoscopp,  the  intHrpre- 
which  are  quite  decided  and  worthy  of  high  coasid-  1  tation  of  its  images,  etc.  The  book  ib  pr-.fusely  and 
eration  The  third  English  edition,  from  which  this  I  ah  y  illuUrated,  and  at  the  end  are  to  be  found  16 
i.s  taken  having  been  revi:,ed  by  the  author,  com-  !  excellent  colored  ophthalmoscopic  figures,  which  are 
prises  t  notice  of  all  the  more  recent  advances  made  copies  of  some  of  the  plates  of  laebreich  s  admirable 
in   ophthalmic  science.    The  style  of  the  writer  is  !  atlas.— iCnnsa*  City  Med.  Journ.,  June,  lb. 4. 

J  A  URENCE  (JOHN  Z.),  F.  R.  C.  S., 

"^  Editor  of  the  Ophthalmic  Review,  &c. 

A  HANDY-BOOK  OF   OPHTHALMIC   £'TTRGERY,  for  the  use  of 

Practitioners.     Second  Edition,  revised  and  enlargeu.     With  numerous  illustrations.     In 
one  very  handsome  octavo  volume,  cloth,  »2  75. 


30  Henry  C.  Lea's  Publications — (Surgery,  &c.). 


rrHOMPSON{SIR  HENRY), 

^  Surgeon  and  Professor  of  Clinicnl  Surgery  to  University  College  Hospital. 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.   With 

illustrations  on  wood.     Second   American  from  the  Third  English  Edition.     In   one  neat 

octavo  volume.     Cloth,  $2  25.      (Just  issued.) 
My  aim  has  been  to  produce  in  the  smallest  possible  compnss  an  epitome  of  practical  knowl- 
edge concerning  the  nature  and  treatment  of  the  diseases  which  form  the  subject  of  the  work  ; 
and  I  venture  to  believe  that  mj'  intention  has  been  more  fully  realized  in  this  volume  than  in 
either  of  its  predecessors. — Author's  Preface.  ^ 


TOT  THE  SAME  AUTHOR. 

ON  THE  PATHOLOGY  AND  TREATMENT  OP  STRICTURE  OP 

THE  URETHKA  AND  URINARY  FISTUL.^.     With  plates  and  wood-cuts.     From  the 
third  and   revised  English  edition.    In  one  very  handsome  octavo  volume,  cloth,  $3  50. 
(Lately  Published.) 
T>¥  THE  SAME  AUTHOR.     (Just  Issutd.) 

THE  DISEASES    OF    THE   PROSTATE,  THEIR   PATHOLOGY 

AND  TREATMENT.     Fourth  Edition,  Revised.     In  one  very  handsome  octavo  volume  of 
355  pages,  with  thirteen  plates,  plain  and  colored,  and  illustrations  on  wood.     Cloth,  $3  75. 


rPAYLOR  {ALFRED  S.),  M.D., 

■*•  Lecturer  on  Med.  Jurisp.  and  Chemistry  in  Ouy's  Hospital 

MEDICAL  JURISPRUDENCE.     Seventh  American  Edition.     Edited 

by  John  J.  Reese,  M.D.,  Prof,  of  Med.  Jurisp.  in  the  Univ.  of  Penn.  In  one  large 
octavo  volume  of  nearly  900  pages.     Cloth,  $5  00;   leather,  $6  00.      (Lately  Issued.) 

In  preparing  for  the  press  this  seventh  American  edition  of  the  "  Manual  of  Medical  Jurispru- 
dence'' the  editor  has,  through  the  courtesy  of  Dr.  Taylor,  enjoyed  the  very  great  advantage  of 
consulting  the  sheets  of  the  new  edition  of  the  author's  larger  work,  "  The  Principles  ami  Prac- 
tice of  Medical  Jurisprudence,"  which  is  now  ready  for  publication  in  London.  This  has  enabled 
him  to  introduce  the  author's  latest  views  upon  the  topics  discussed,  which  are  believed  to  bring 
the  work  fully  up  to  the  present  tiuie. 

The  notes  of  the  former  editor.  Dr.  Hartshorne,  as  also  the  numerous  valuable  references  to 
American  practice  and  decisions  by  his  successor,  Mr.  Penrose,  have  been  retained,  with  but  few 
slight  exceptions;  they  will  be  found  inclosed  in  brackets,  distinguished  by  the  letters  (U.)  and 
(P.).  The  additions  made  by  the  present  editor,  from  the  material  at  his  command,  amount  to 
about  one  hundred  pages;   and  his  own  notes  are  designated  by  the  letter  (R.). 

Several  subjects,  not  treated  of  in  the  former  edition,  have  been  noticed  in  the  present  one, 
and  the  work,  it  is  hoped,  will  be  found  to  merit  a  continuance  of  the  confidence  wliich  it  has  so 
long  enjoyed  as  a  standard  authority. 

T>Y  THE  SAME  AUTHOR. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.  Second  Edition,  Revised,  with  numerous  Illustrations.  In  two  large  octavo 
volumes,  cloth,  $10  00;  leather,  $12  00 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Ameri- 
can profession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country. 

-DY  THE  SAME  AUTHOR.     (New  Edition— .Juxt  Wmed.) 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDEXCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 

large  octavo  voluiue  of  SaO  pages  ;  cloth,  $5  50  ;  leather,  $6  60. 
This  work,  which  has  been  so  long  recognized  as  a  leading  authority  on  its  important  subject, 
has  received  a  very  thorough  revi.-ion  at  the  hands  of  the  author,  and  may  be  regarded  as  a 
new  book  rather  than  as  u  mere  revision.  He  has  sought  to  bring  it  on  all  points  to  a  level 
with  the  advanced  science  of  the  day;  many  portions  have  been  rewritten,  much  thnt  was  of 
minor  importance  has  been  omitted,  and  every  eliort  made  to  condense  a  comjilele  view  of  the 
subject  within  the  limits  of  a  single  volume.  Dr.  Taylor's  position  as  an  expert  has  brought 
him  into  connection  with  ne;irly  ail  important  cases  in  England  for  many  years,  lie  thus  speaks 
with  an  authority  that  few  other  living  men  possess,  while  his  intimate  acquaintance  with  the 
literature  of  toxicology  on  both  sides  of  the  Atlantic,  renders  his  work  equally  adapted  as  a 
text-book  in  this  country  as  in  Great  Britain. 


To  tbe  members  of  the  legal  and  medical  profession 
it  is  UDnecessary  to  fiay  anytbiug  commendatory  of 
Taylor's  .Medical  Jurisprudence  We  migliC  as  well  un- 
dertiike  to  speak  of  iLie  merit  of  Ubittys  Pieadiugs. — 
Vhicaiji,  Legal  ^t'l-tos,  Oct.  16,  1S73. 

This  last  edition  of  the  Manual  is  probably  the  best 
of  ail,  lis  it  contains  more  material  and  is  worked  up  to 
the  latest  views  of  the  author  as  expre.s.sed  in  the  last 


edition  of  the  Principles.  Dr.  Reese,  the  editor  of  the 
.Manual,  has  duuo  everything  to  make  bis  %¥ork  acceptr 
able  to  hi.s  me.Jicai  couutrymen.  —  Acw  I'urk  Medical 
Itec'ird,  Jan.  15,  1874. 

It  is  beyond  question  the  most  attractive  as  well  aA 
most  reliable  manual  of  medical  jurisprudence  published 
m  the  En;rlisb  language. — Anttricau  Jnuiital  lif  HyplUlo- 
^rapky,  Uct.  1S73. 


Henry  C.  Lea's  Fv^iLJOATJOias— {Psychological  Medicine,  &c.).      31 


rPTJKE  {DANIEL  HACK),  M.D., 

■*■  Joint  author  of  "  The  Manual  of  Psychological  Medicine,^'  &c. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HKALTH  AND  DISEASE.  Designed  to  illustrate  the  Actiun  of  the 
Imagination.  In  one  handsome  octavo  volume  of  416  pages,  cloth,  $3  25.  (Just  Issued.) 
The  object  of  the  author  in  this  work  has  been  to  show  not  only  the  effect  of  the  mind  in  caus- 
ing and  intensifying  disease,  hut  also  its  curative  influence,  and  the  use  which  may  be  made  of 
the  imagination  and  the  emotions  as  therapeutic  agents.  Scattered  facts  bearing  upon  this  sub- 
ject have  long  been  familiar  to  the  profession,  but  no  attempt  has  hitherto  been  made  to  collect 
and  systematize  them  so  as  to  render  them  available  to  the  practitioner,  by  establishing  the  seve- 
ral phenomena  upon  a  scientific  basis.  In  the  endeavor  thus  to  convert  to  the  use  of  legitimate 
medicine  the  means  which  have  been  emplo^'ed  so  successfully  in  many  systems  of  quackery,  the 
author  has  produced  a  work  of  the  highest  freshness  and  interest  as  well  as  of  permaneul  value. 


DLANDFORD  [G.  FIELDING),  M.  D.,  F.  R.  C  P., 

•*-'  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George'.i  Hospital,  &e. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and   Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on   the  Confinement  of  the  Insane.     By  Isaac  Ray,  M.  D.     In  one  very 
handsome  octavo  volume  of  471  pages;  cloth,  $3  25. 
This  volume  is  presented  to  meet  the  want,  so  frequently  expressed,  of  a  comprehensive  trea- 
tise, in  moderate  compass,  on  the  pathology,  diagnosis,  and  treatment  of  insanity.    To  render  it  of 
more  value  to  the  practitioner  in  this  country.  Dr.  Ray  has  added  an  appendix  which  atTords  in- 
formation, not  elsewhere  to  be  found  in  so  accessible  a  form,  to  physicians  who  may  at  any  moment 
be  called  upon  to  take  action  in  relation  to  patients. 

It  satisfies  a  want  which  must  have  beeu  sorely  actually  seen  in  practice  and  the  appropriate  treat- 
felt  by  the  busy  general  practitioners  of  this  country.  :  ment  for  them,  we  find  in  Dr.  Blandford's  work  a 
It  takes  the  form  of  a  manual  of  clinical  description 
of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  giving  it  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varieties  of  insanity  as 


considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fall 
to  be  struck  with  their  superiority  to  those  given  in 
ordinary  manuals  In  the  English  language  or  (so  far 
as  our  own  reading  extends)  in  any  other. — London 
Practitioner,  i'eb.  1S71. 


W: 


INSLOW  [FORBES),  M.D.,  D.C.L.,  ^c. 

ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS 

OF  THE  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro- 
phylaxis. Second  American,  from  the  third  and  revised  English  edition.  In  one  handsome 
octavo  volume  of  nearly  600  pages,  cloth,  $4  25. 


TEA  [HENRY  C). 
■^SUPERSTITION    AND    FORCE:    ESSAYS    ON    THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.     Second  Edition, 
Enlarged.      In  one  handsome  volume  royal  12mo.  of  nearly  600  pages;  cloth,  $2  75. 
{Lately  Published.) 
We  know  of  no  single  work  which  contains,  in  so  i  interesting  phases  of  human  society  and  progress.  . 
.mail  a  compass,  so  much  illustrative  of  the  strangest  I  The  uilness  and  breadth  with  which  he  has  carried 


As  a  work  of  curious  inquiry  on  certain  outlying 
points  of  obsolete  law,  "Superstition  and  Force"  is 
one  of  the  most  remarkable  books  we  have  met  with. 
London  Athenaum,  Sov.  3,  1866. 

He  has  thrown  a  great  deal  of  light  upon  what  must 
be  regarded  as  one  of  the  most  instructive  as  well  as 


pliUosophi 

Lea's  labors  of  sterling  value  to  the  historical  sio- 

dent.— Z/0»i(io/i  Saturday  Revitw,  Oct,  »,  1S7U. 

As  a  book  of  ready  reference  on  the  subject,  it  is  of 
the  highest  vaXna.—  WestmituiterHevieie,  Oct.  18ti7. 


B 


Y  THE  SAMS  AUTHOR.    (Latey  PiMhshtd.) 

STUDIES  IN  CHURCH  HISTORY-THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.  In  one  large  royaJ 
12mo.  volume  of  616  pp.  cloth,  $2  76. 
The  slorv  was  never  told  more  calmly  or  with  ,  literary  phenomenon  that  the  head  of  one  of  the  flr»l 
«Iler  leaTnilg  or  wi 'er  thought.  We  doubt,  indeed,  American  houses  s  also  the  writer  of  some  of  ts  mo»l 
ff  any  other  «mdy  of  this  tield'can  be  compared  with  ]  original  books. -Lon,^,a  Mh^na^.m  i^u.l  IM 
this  for  clearness,  accuracy,  and  power.  — CAicdj/o  i  jir.  Lea  has  done  great  honor  to  hiuiself  and  IHU 
Examiner,  Dec.  1S70.  .         country  by  the  admirable  work,  he  ha.  written  on 

Mr  T«M'slatestwork  "Studies  in  Church  History,"  '  ecclesiologicaland  cognate  subjoct8_  We  havealready 
Mr.  Lea  6 latest  worK,     oiuuiboiuv,       , ,  ,     ,    ^Yth  '  had   occasion   to  commend    his   "Superstition    and 
fully  sustains  the  promise  ot  ^^  P.Lr     HlnltiT  of  i  Force"   and  his  "History  of  Sacerdotal   Celibacy." 

works   as  these-wilh^ which   that   on   "Sacerdotal  I  i-^tfcW   .tf«d.em«,  July.  18-0. 
CeUbacy"  should  be  included— without  noting  the  i 


32 


Henry  C.  Lea's  Publications. 


INDEX    TO    CATALOGCTE. 


American  Joarnal  of  tbe  Medical  Sciences 

Aboiract,  Half-Yearly,  of  the  Med   Sciences 

Anatomical  Atlas,  by  Smith  and  Horner 

Anders-on  on  Diseases  of  the  Skin 

Ashton  on  the  Kectnm  and  Anus 

Attfield's  Chemistry 

Ashwell  on  Diseases  of  Females 

Ashhurst's  Surgery 

Barnes  on  Diseases  of  Women 

Bellamy's  Surgical  Anatomy 

Bryant's  Practical  Surgery     . 

Bloxam's  Chemistry 

Blandford  on  Insanity    . 

Basham  on  Renal  Diseases    . 

Brinton  on  the  Stomach 

Bigelow  on  the  Hip 

Barlow's  Practice  of  Medicine 

Bowman's  (John  E.)  Practical  Chemistry 

Bowman's  (John  E.)  Medical  Chemistry 

Bristowo's  Practice  .... 

Bruntou's  Materia  Medica 

Bnmstead  on  Venereal  .... 

Bamstead  and  Cuilerier's  Atlas  of  Venereal 

Carpenter's  Human  Physiology    . 

Carpenter's  Comparative  Physiology   . 

Carpenter  on  the  Use  and  Abuse  of  Alcohol 

Carter  on  the  Eye 

Century  uf  American  Medicine 
Chambers  on  Diet  and  Regimen 
Chambers's  Restorative  Medicine 
Christison  and  Griffith's  Dispensatory 
Churchill's  System  of  Midwifery  . 
Churchill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children     . 
Cooper's  (B.  B.)  Lectures  on  Surgery    . 
Cuilerier's  Atlas  of  Venereal  Diseases 
Cyclopedia  of  Practical  Medicine  . 
Dalton's  Human  Physiology  . 
Davis'  Clinical  Lectures 
Dewees  on  Diseases  of  Females     . 
Dewees  on  Diseases  of  Children    . 
D  mitt's  Modern  Surgery 
Dunglison'e  Medical  Dictionary    . 
Dunglison's  Human  Phy.^ioiogy    . 
Danglison  on  New  Remedies 
Ellis's  Medical  Formulary,  by  Smith   . 
Brichsen's  System  of  Surgery 
Fenwick's  Diagnosis       .•       .        .        . 
Flint  on  Respiratory  Organs  . 

Flint  on  tlie  Heart 

Flint's  Pr.ictice  of  Medicine  . 

Flint's  Essays 

Flint  on  Phthisis 

Flint  ou  iVrcussinn  .... 

Folhergills  Handbook  of  Treatment     . 
Fowneo  s  Elementary  Chemistry  . 
Fox  on  Diseases  of  the  Stomach     . 
Fox  on  Diseases  of  the  Skin   . 
Fnlleron   the  Lungs,  &c. 
Green's  Pathology  and  Morbid  Anatomy 

Gibson  s  Surgery 

Glnge's  Pathological  Histology,  by  Leidy 
Galloway's  Qualitative  Analysis  . 

Gray's  Anatomy 

Griffith's  (R.  E.)  Universal  Formulary 

Gross  ou  Urinary  Organs 

Gross  on  Foreign  Bodies  in  Air-Passages 

Gross's  Principles  and  Practice  of  Surgery 

Gosselin's  Clinical  Lectures  on  Surgery 

Hamilton  on  Dislocations  and  Fractures 

Hartshorne's  Essentials  of  Medicine     . 

Hartshorne's  Conspectus  of  the  Medical  Science 

Hartshorne's  Anatomy  and  Physiology 

Heath's  Practical  Anatomy    . 

Hoblyn's  Medical  Dictionary 

Hodge  on  Women    ... 

Hodge's  Obstetrics  . 

Hodges'  Practical  Dissections 

Holland's  Medical  Notes  and  Reflections 

Holmes's  Surgery    ... 

Horner's  Anatomy  and  Histology 

Hudson  on  Fevers 


1 
3 

6 
20 
28 
10 
23 
27 
22 

7 
29 
11 
31 
18 
17 
2S 
14 
11 
il 
10 
14 
19 
19 

S 

S 

13 
29 


Hill  on  Venereal  Diseases     .        .        , 
lillier's  Handbook  ot  Skin  Diseases 
Jones  (C.  HandUeld)  on  Nervous  Disorders 
Kirkes'  Physiology         .... 
Knapp's  Chemical  Technology 
Lea's  Superstition  and  Force 
Lea's  Studies  in  Church  History  . 

Lee  on  Syphilis 

Lincoln  on  Electro-Therapeutics   . 
Leishman's  Midwifery     .... 
La  Roche  on  Yellow  Fever  . 
La  Roche  on  Pneumonia,  &c. 
Laurence  and  Moon's  Ophthalmic  Surgery 
Law.son  on  the  Eye  .... 

Laycock  on  Medical  Observation  . 
Lehmann's  Physiological  Chemistry,  2  vol 
Lehmann's  Chemical  Physiology  . 
Ludlow's  Manual  of  Examinations 

Lyons  on  Fever 

Maclise's  Surgical  Anatomy  . 

Marshall's  Physiology    .... 

Medical  News  and  Library    . 

Meigs  on  Puerperal  Fever 

Miller's  Practice  of  Surgery  . 

Miller's  Principles  of  Surgery 

Montgomery  on  Pregnancy    . 

Neill  and  Smith's  Compendium  of  Med.  Science 

Neligan's  Atlas  of  Diseases  of  the  Skin 

Obstetrical  Journal         .... 

Odling's  Practical  Chemi.stry 

Parry  on  Extra-Uterine  Pregnancy 

Pavy  on  Digestion  .... 

Pavy  on  Food 

Parrish's  Practical  Pharmacy 

Pirrie's  System  of  Surgery     . 

Pereira's  Mat.  Medica  and  Therapeutics,  abridged 

Playfair's  Midwifery       .... 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

Roberts  on  Urinary  Diseases  . 

Ramsbotham  on  Parturition  . 

Rigiy's  Midwifery 

Rodwell's  Dictionary  of  Science     . 

Swayne's  Obstetric  Aphorisms 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Skey's  Operative  Surgery 

Slade  on  Diphtheria        .... 

Smith  (J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomical  All 

Smith  (Edward)  on  Consumption  . 

Smith  on  Wasting  Diseases  in  Children 

Still6'8  Therapeutics        .... 

Stnrges  on  Clinical  Medicine 

Stokes  on  Fever      ..... 

Tanner's  Manual  of  Clinical  Medicine  . 

Tanner  on  Pregnancy     .... 

Taylor's  Medical  Jurisprudence 

Taylor's  Principles  and  Practice  of  Med   Jurisp 

Taylor  on  Poisons  . 

Tuke  on  the  Influence  of  the  Mind 

Thomas  on  Diseases  of  Females    . 

Thompson  on  Urinary  Organs 

Thompson  on  Stricture    .... 

Thompson  on  the  Prostate 

Todd  on  Acute  Diseases  .... 

Walshe  on  the  Heart      .... 

Watson's  Practice  of  Physic  . 

Wells  on  the  Eye 

West  on  Diseases  of  Females 
Weston  Diseases  of  Children 
Weston  Nervous  Disorders  of  Children 
What  to  Observe  in  Medical  Cases 
Williams  on  Consumption 
Wilson's  Human  Anatomy    . 
Wilson  on  Diseases  of  the  Skin 
Wilson's  Plates  on  Diseases  of  the  Skin 
Wilson's  Handbook  of  Cutaneous  Medicine 
Winslow  on  Brain  and  Mind 
Wijhler'g  Organic  Chemistry 
Winckel  on  Childbed      .... 
Zeissl  on  Venereal 


PAGB 
19 


For  "The  Obstetrical  Journal,"  Five  Dollars  a  year,  see  p.  23. 


FORNIA  LIBRARY 


.^•. 


THE  LTBRARY 


XTT* 


'/Ma 


'¥-A. 


